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ALUMNI BULLETIN 



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ccess for All 



Guidelines for 
Healthful Eatin 



American Heart 
Associations 




The American 
Heart Association 
says - that on 
average -your 
daily diet should 
not include 
more than: 



Get in on the Action 



Vigorous activities done for 30-60 minutes, 
3-4 times weekly, offer these benefits: 

Improves circulation 

Controls weight 

Prevents and manages 
high blood pressure 

Lowers blood cholesterol levels 

Raises HDL-cholesterol levels 

Boosts energy levels 



American Heart | 
AssociationsM 



Fiahtina Heart Disease 



©1996, American Heart Association 




Spring 1997 
Volume 70 Number 4 



Harvard Medical 



ALUMNI 



BULLETIN 




The Family Van. Photo by 
Stuart Darsch 



12 On the Road to Reform 

by Arnold Epstein 

The failure of federal health care 

reform was only the beginning. 

16 Two Heads Are Better Than One 

by Joshua Shaif stein 
More merger madness! 

18 Competition Among Friends 

by Ellen Barlow 
It's a new game for the 
Harvard affiliates. 
The Other Twelve 

30 Complexion of Change 

by Jordan J. Cohen 

Finishing the bridge to diversity. 

Enriched by Diversity 

by Gerald S. Foster 

36 Taking it to the Streets 

by Janet Walzer 

The Family Van brings health care 

on wheels. 

A Respected Option 

42 Legacy of AIDS 

by Harvey J. Makadon 

How an epidemic has transformed 

people, medicine and society. 



Departments 

3 Letters 

4 Pulse 

Gender differences, protein culprit 
in Alzheimer's disease, beta blockers 
and heart attacks, historic painting, 
MD-PhD alumni survey. 

9 Commentary 

by Victoria McEvoy 

10 Book Mark 

The Eye of the Artist by Michael F. 
Marmor and James G. Ravin; 
reviewed by Judith and John Dowling. 

51 Alumni Notes 

54 Alumnus Profile 

David Ho 

56 In IVIemoriam 

Lamar Soutter 
Chiu-An Wang 

59 Death Notices 



47 Medicine in Coal Country 

by Daniel Doyle 

Care for the community means 

no one is left out. 



Inside hmab 



Harvard Medical 



A L U M N 



BULLETIN 



"Who loses and who wins; who's in, who's out. . ." That, to bor- 
row the line from Lear, is the central problem of medicine as the 
half century of its greatest triumph comes to a close. 

Franklin Roosevelt had no access to either the immunization 
that would have prevented his poliomyelitis or the drugs that 
could have lowered his blood pressure and prevented his fatal 
stroke in 1945. The best that he could afford, with his consider- 
able fortune, gave him relatively little medical advantage over the 
poorest of Americans at the depth of the Great Depression. 
Since he died, polio has been all but eliminated in developed 
countries and the morbidity and mortality from strokes substan- 
tially reduced. 

Saving lives, however, has not saved money. Indeed, improved 
technology has been a driving force behind the rising costs of 
health care. People are living longer. Paradoxically, the triumph 
of effective medicine bids has made it a yet scarcer resource, not 
a more plentiful one. Who then is to have access to medical care? 

In this issue of HMAB we look at the problem of access from 
various angles. Ellen Barlow, editor of the Bulletin, brings us up 
to date on the mergers among Harvard hospitals; institutions 
that once seemed as stable as tectonic plates have been crashing 
into each other, making familiar boundaries obscure. Traveling 
to the medical antipodes, Boston's poorest neighborhoods, Janet 
Walzer, our associate editor, describes an effort to breach barri- 
ers to access that are more than monetary. Far from the inner 
city, Daniel Doyle '72 reports on efforts to provide health care in 
Appalachia. 

Arnold Epstein, from the vantage point of an eyewitness to 
the Clinton's efforts at forging a new national health policy, ana- 
lyzes the course of events since then, and warily ventures some 
predictions about the next phase. Jordan Cohen '60, president of 
the Association of American Medical Colleges, explains why 
training minority students improves the care of the underserved. 
Harvey Makadon explores the legacy of AIDS and the lessons we 
have learned. And Joshua Sharfstein '96 looks at merger mania 
through a student's glass — darkly. 

William Ira Bennett '68 



Editor-in-chief 

William Ira Bennett '68 

Editor 

Ellen Barlow 

Associate Editor 

Janet Walzer 

Assistant Editor 

Sarah Jane Nelson 

Book Review Editor 

Elissa A. Ely '88 

Editorial Board 

Elissa A. Ely '88 
Melinda Fan '96 
Robert M. Goldwyn '56 
Joshua Hauser '95 
Paula A. Johnson '84 
Victoria McEvoy '75 
James J. O'Connell '82 
Gabriel Otterman '91 
Deborah Prothrow-Stith '79 
Guillermo C. Sanchez '49 
J. Gordon Scannell '40 
Eleanor Shore '55 
John D. Stoeckle '47 

Design Direction 

Sametz Blackstone Associates, Inc. 

Association Officers 

Suzanne Fletcher '66, president 
Robert S. Lawrence '64, president-elect i 
George E. Thibault '69, president-elect 2 
Roman W. DeSanctis '55, vice president 
David D. Oakes '68, secretary 
Arthur R. Kravitz '54, treasurer 

Councillors 

David P. Gilmour '66 
Laurie R. Green '76 
Katherine L. Griem '82 
Gerald T. Keursch '62 
Dana Leifer '85 
Alison G. May '91 
Sharon B. Murphy '69 
Gilbert S. Omenn '65 
John B. Stanbury '39 

Director of Alumni Relations 

Daniel D. Federman '53 

Representative to the Harvard Alumni Association 

Chester d'Autremont '44 

ID Statement: 

The Hm-uard Medical Ahmmi Bulletin is pubhshed 
quarterly at 25 Shattuck Street, Boston, MA 02 1 15 
© by the Harvard Medical Alumni Association. 
Telephone: (617) 432-1548. Email address: 
bulletin@warren.med.harvard.edu. Third class postage 
paid at Boston, Massachusetts. Postmaster, send form 
3579 to 25 Shattuck Street, Boston, MA 02 11 5, 
ISSN 0191-7757. Printed in the U.S.A. 



Harvard Medical Alumni Bulletin 



Letters 



Patient Suffering 

On page 3 1 of the Winter issue, Linda 
Emanuel is quoted as stating: "I have 
never seen a case of patient suffering 
that could not be handled by aggres- 
sive palliative care." 

While I am not famihar with the 
range of Dr. Emanuel's clinical experi- 
ence, I would call her attention to the 
plight of men with advanced prostatic 
cancer and multiple bone metastases 
with frequent pathological fractures. 
Some are produced merely by turning 
over in bed. Do not forget that a 
pathological fracture is just as painful 
as a fracture in normal bone. The same 
is true of some women with late breast 
cancer. 

Some burn patients come to mind, 
especially young adults with terrible 
gasoline burns from automobile acci- 
dents, around the head, shoulders, 
face, often obliterating all the features 
of the face. As these third-degree 
burns separate and slough, left behind 
is a granulating surface richly inner- 
vated by all the nerves of the normal 
face. Here is suffering not relieved by 
any means we have except early skin 
grafting, though assuredly not an invi- 
tation to assisted suicide. 

These and other examples come to 
mind in relation to Emanuel's rather 
sweeping and unrealistic statement. 
Don't forget that "snowing" patients 
with repeated massive doses of mor- 
phine produces severe constipation 
and obstipation, fecal impaction, and 
sometimes rupture of the sigmoid. 
Cordotomy and frontal lobotomy can 
sometimes be used, but are terribly 
disabling. 

Although assisted suicide might 
become a refuge only in very rare 
cases, it is totally unrealistic to state 
that current conventional palliative 
methods will take care of all forms of 
human agony. 

Frances D. Moore '39 



Remembering Denny-Brown 

The Winter issue of the Bulletin was 
superb and I particularly enjoyed the 
article by Sid Shulman and Joel 
Vilensky about Denny-Brown. It was 
so characteristic and well done, and it 
recalled my own memories of Denny- 
Brown. 

He and I were separated by thou- 
sands of miles, he in India and I in 
New Guinea in World War II, but 
after the war I became a neurosurgeon 
and was appointed to the Board of 
Scientific Counselors of the National 
Institute of Neurological Diseases and 
Blindness, of which he was a member. 
It was a genuine education to be with 
him and he was a clearly frank and 
outspoken person. On one occasion 
when we were talking to the director, 
he was exasperated and said, "What I 
don't understand is what this neuro- 
logical institute is doing here anjrway." 
He was talking about the huge clinical 
research center at the NIH. 

Harvard has had outstanding peo- 
ple in neurology all these years, partic- 
ularly with Houston Merritt and 
Bronson Crothers in children's neu- 
rology. 

Eben Alexander '39 

One of the Best 

Sissela Bok's article in the recent 
Bulletin was one of the best I've read 
on the subject. I happen to be in the 
middle of her book Lying, which I am 
also enjoying. 

Richard Wilson '76 



Tlie Ultimate Connection 

Thank you so much for another excel- 
lent issue of the Bulletin. I particularly 
enjoyed "Death on the Streets" by my 
classmate Jim O'Connell. It was a fine, 
heartfelt and moving piece of writing. 

"My Patients, My Self is such a 
timely article. In the emergency 
department I see patients at or near 
the end of life every week. It is so good 
to see that HMS is offering a course to 
help developing physicians learn the 
essential need these folks and their 
families have for acknowledging their 
experience. They are living examples 
of the human condition and the ulti- 
mate connection our inevitable mor- 
tality gives us all. 

Charles Hartness '82 

Dual Degrees 

I have always enjoyed saving my copies 
of the Harvard Medical Alumni Bulletin, 
for I have found there has been a great 
advantage in re-examining and re- 
reading the articles over time. 

The other day I chanced to read 
David A. Shaywitz's article, "The 
Physician-Scientist: Dual or Dueling 
Degrees?" which appeared in the 
Summer 1995 issue. I came upon the 
following statement: "Doing both sci- 
ence and medicine well is possible in 
certain fields, less achievable in oth- 
ers," agrees Stuart Lipton, a neurolo- 
gist and neurobiologist at Harvard 
Medical School. "It would be very dif- 
ficult in neurosurgery; for example, if 
you're choosing a surgeon, you want 
one who operates at least every other 
day. In medicine, while you need an 
intense initial training, it is not neces- 
sary to be in clinic every day." 

I cannot disagree more with Dr. 
Lipton's belief that a neurosurgeon 
cannot simultaneously be both a labo- 
ratory scientist and an accomplished 
surgeon. I have spent over 40 years 
involved in both surgery and investiga- 



Spring 1997 



Letters 



Pulse 



tion of the central nervous system. 
There are many other neurosurgeons 
who have contributed to both the chn- 
ical and the experimental fields during 
the last few decades. This is true not 
only of neurosurgeons but other fields 
of surgery, and while we are on the 
subject, we should not forget the sur- 
geons (although no neurosurgeons) 
who have received the Nobel Prize in 
Medicine or Physiology. 

Sorry to be so late in my response, 
but perhaps a good article is like wine 
in that with time it only becomes 
better! 

RohenJ. White '53 



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Gender Makes a Difference 

Although differences in how men and 
women communicate might not be a 
new story, what is new is how these 
differences can affect patient care. For 
example, women physicians spend 
close to 1 3 percent more time with 
their patients than their male counter- 
parts. This is one of the findings 
reported by Lucy Candib '72 in her 
December talk as part of the Cabot 
Primary Care Series. 

Candib, professor of family and 
community medicine at University of 
Massachusetts, reviewed data from 
several studies, including the National 
Ambulatory Care Survey. In a study 
performed at 1 1 ambulatory care sites 
and small group practices it was found 
that women physicians spent an aver- 
age of 22.9 minutes with their patients 
as opposed to men physicians who 
spent 20.3 minutes. Interestingly, 
women spent more time with their 
female patients (23.3 minutes versus 
22.3 minutes) and men physicians 
spent more time with their male 
patients (21.5 minutes versus 19.4 
minutes). 

One way this additional time by 
women physicians is used is on screen- 
ing and prevention, says Candib. In a 
study of colorectal cancer surveillance 
at George Washington University 
Medical Center, 37.9 percent of 
women's patients were tested for fecal 
occult blood as opposed to 27.5 per- 
cent of men's patients. Women physi- 
cians also performed more 
sigmoidoscopies (37.9 percent) than 
men physicians (23.3 percent). 

In a smaller study of family practice 
residents female residents were more 
likely than men residents to do screen- 
ing tests such as mammograms, pelvic 
exams and Pap smears. Similarly, in a 
larger study of 25,000 women patients 
in Minnesota, it was found that women 
physicians were doing more Pap 



smears than men physicians. 

Although Candib acknowledged 
that some data in these studies were 
inconsistent, she pointed out that an 
"increased tendency to screen our own 
gender seems to emerge as a relatively 
consistent effect." 

Candib, who is also a family physi- 
cian in Worcester and author of 
Medicine and the Family: A Feminist 
Perspective, noted that studies also 
demonstrate that women physicians 
talk to their patients more than men 
physicians. And in return, "Women 
physicians get a whole lot more infor- 
mation back from patients," observes 
Candib. 

Yet Candib does not believe that 
communication is "inherently gender 
based." Physicians can learn commimi- 
cation skills, says Candib. She advises 
doctors to reflect on how gender influ- 
ences their practices. "We do have a 
choice about how we communicate 
with others." 



Harvard Medical Alumni Bulletin 




Dennis Selkoe 



Protein Culprit in Alzlieimer's Disease 

Researchers used to believe that tan- 
gles and plaques — the hallmarks of 
Alzheimer's disease — were just arti- 
facts of the disease but not the direct 
cause. This may well be true for tan- 
gles, but new evidence that builds on 
his work reported four years ago has 
convinced Dennis Selkoe, HMS profes- 
sor of neurology at Brigham and 
Women's Hospital, that plaques are in 
fact a major cause of the disease. 

Four years ago Selkoe and col- 
leagues found that even normal human 
brain cells produce amyloid beta pro- 
tein (A beta), the protein found in 
plaques. This raised the possibility that 
Alzheimer's disease might actually be a 
direct consequence of an overproduc- 
tion of A beta. 

Now, Selkoe and collaborators in 
his and other laboratories have addi- 
tional evidence that this is the major 
causal mechanism. They reported in 
the January 1997 Nature Medicine that 
when two mutant Alzheimer's genes, 
presenihn i and presenilin 2, were 
transfected into normal human kidney 
cells, production of a particular form 
of A beta (A beta 42) doubled. 

"Given that this occurs directly in 
cultured cells in the absence of the dis- 
ease state, it's clear the doubling is not 
a secondary effect," says Selkoe. 

These findings come on the heels 
of an earlier discovery by Seiko and 
Cynthia Lemere, HMS instructor in 
neurology, that Alzheimer's patients 
with mutant presenilin i genes have 
double the usual level of plaques con- 
taining A beta 42 in their brains. They 
reported these results in the August 
1996 issue oi Nature Medicine. 



If overproduction of A beta 42 is a 
cause of some forms of Alzheimer's 
disease, as Selkoe believes, then one 
strategy for fighting the disease would 
be to selectively turn down production 
of the protein. Martin Citron and 
Selkoe reported in the November 
1996 Pi'oceedings of the National 
Academy of Sciences that such a strategy 
has been found to work for the other 
form of A beta, A beta 40. (A beta 
comes in two lengths, A beta 40 and A 
beta 42 , which differ by just two amino 
acids.) 

Ultimately, Selkoe and his col- 
leagues hope to prevent Alzheimer's 
disease as well as treat it. "My vision is 
that as part of a health screening ten 



years from now, you'll have your blood 
level of A beta 40 and A beta 42 
checked," he says. He speculates that 
clinical trials of A beta blockers could 
perhaps begin as early as 1999, and 
that in ten years, "doctors could have a 
whole armamentarium of anti- 
Alzheimer's drugs even beyond these." 



Selkoe's colleagues (left 
to right): Cynthia Lemere, 
Sayeon Kim, Martin 
Citron, Weemlng XIa and 
Thelka DIehl 




Spring 1997 



Pulse 



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HMS '66 

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Beta Blockers Can Save Lives 

Elderly patients who take beta block- 
ers after surviving heart attacks have 
43 percent less chance of dying in the 
two years post attack than those who 
do not take the drug. Such are the 
findings reported by Harvard 
researchers in the January 8, 1997 
issue of the Journal of the American 
Medical Association. 

The study, led by Stephen B. 
Soumerai, associate professor of ambu- 
latory care and prevention at HMS and 
Harvard Pilgrim Health Care, is the 
first of its kind to examine the use of 
beta blockers in heart attack patients 
over the age of 65. Indeed, patients 
over the age of 75 have never been 
included in previously randomized tri- 
als studying the protective effects of 
beta blockers, says Soumerai. "This is 
remarkable. We're talking about a very 
at-risk population." 

Only one in five patients are actu- 
ally given beta blockers after heart 
attacks. This underuse could be 
deadly, as Soumerai estimates that 
thousands of lives might be saved by 
beta blockers. Although it is not clear 
why beta blockers are underused, the 
authors hypothesize that physicians 
still have concerns about potential side 
effects, such as depression and heart 
failure. Yet the data on beta blocker 
effectiveness is so convincing that 
Soumerai says, "Some physicians joke 
that we should put them in the water 
supply." 



The federally funded study exam- 
ined 5,332 Medicare patients in New 
Jersey between 1987 and 1992, of 
whom 3,737 were deemed eligible for 
beta blocker use. These patients, how- 
ever, were three times more likely to 
receive calcium-channel blockers, a 
much costlier drug and not as effec- 
tive. The use of calcium-channel 
blockers placed these patients at twice 
the risk of death because they were 
substituted for beta blockers. 

Soumerai's coauthors are Thomas 
McLaughlin of HMS and HPHC, Donna 
Spiegelman and Ellen Hertzmark of 
HSHP, George Thibault '69 of HMS and 
Brigham and Women's Hospital and 
Lee Goldman of UCSF. 



Harvard Medical Alumni Bulletin 




Leroy D. Vandam, Joseph 
E. Murray '43B and 
Francis D. Moore '39. 



An Historic Unveiling 

More than 50 people gathered at the 
Countway Library on December 20, 
1996, for the unveihng of the painting 
that commemorates the first successful 
human organ transplantation. 
Members of the historic transplant 
team, Leroy D. Vandam, professor 
emeritus of anesthesia, Joseph E. 
Murray, professor emeritus of surgery, 
and Francis D. Moore, Moseley 
Professor Emeritus of Surgery, com- 
missioned the painting from Joel Babb, 



of Buckfield, Maine, and donated it to 
Harvard University. Dean Tosteson 
accepted the work on Harvard's behalf 
at the event. The portrait depicts the 
operation as it was being carried out at 
the Peter Bent Brigham hospital on 
December 23, 1954. The painting now 
hangs in the library's main lobby, 
across from the Robert Hinckley 
painting, "First Operation Under 
Ether." 




Spring 1997 



Pulse 



MD-PhD Alumni Survey Results 

A recent sun'ey conducted by 
Harvard's MD-pHd program indicates 
that no one should be disappointed in 
the accomphshments of these dual- 
degree recipients. 

In 1964 the NIH established the first 
medical scientist training program 
(mstp) to offer the combined MD-pho 
degree. It was hoped that these physi- 
cian-scientists would become tomor- 
row's leaders in scholarship, teaching 
and research. With Harvard estab- 
lished as one of the largest programs in 
the country (150 in the current MD- 
PhD class), there are now 3 3 of these 
programs nationally, supported in 
large part by the NIH. 

Survey results of HMS MD-pho 
alumni indicate that of the 107 men 
and women who have finished their 



postdoctoral training, there are two 
NIH chiefs, nine full professors, 24 
associate professors, 50 assistant pro- 
fessors and nine instructors. Currently 
there are nine graduates who work in 
industry: two CEOs, two vice presi- 
dents, two division directors and three 
senior research scientists. While 87 
individuals are still completing their 
residencies and fellowships, two are in 
private practice. The highest number 
of graduates are in departments of 
medicine (64), followed by 16 gradu- 
ates in surgery, 14 in pathology, 14 in 
pediatrics, 1 2 in neurology and 1 2 in 
neurosurgery. 

An overwhelming majority of those 
surveyed (96 percent) believe that 
their dual-degree training was impor- 
tant to their careers, although a 
smaller number believed that either an 



MD or a PhD would have been adequate 
for their careers. And 40 percent of 
respondents noted that their careers 
have been what they expected when 
they first entered the MD-Pho pro- 
gram. 




Dartmouth 

Medical School 

1797-1997 



Great Issues for Medicine in tlie 21st Century 

A CONSIPEKATION OF THE ETIIICAI. A!^I> SOCIAI. ISSUES 

ARISIMG OET OF AI>¥A]^CES IN THE BIOMEDICAL SCIENCES 

A Program in Celebration of tiie Dartmoutii Medical School Bicentennial 

Cocliaiis: Nobel Laiueates .Foseph L. Goldstein and Michael S. Brown 

For program details, call 603/650-'i03? (No Registiation Fees: Certified for AMA Categon? 1 credit) 



FitlPAY, SEPTEMBER 5 
Opening Session: 8:30 a.m. 

Andrew G. Wallace. Dean. Dartmouth Medical School 
.James 0. Freednian. President, Dartmouth College 
.losepli L. Goldstein, Cochair, Bicentennial Spnposium 

Genetics: 10:00 a.m. 

David Botstein. Chair, Department of Genetics, Stanford 
Richard Axel, Professor of Biochemistry, Columbia 
Francis Collins, Director, National Human Genome Institute 
Nancy Wexler. Hereditary Disease Foundation 

I^Ieuroseienee: 3:30 p.m. 

Pasko T. Rakic. Chair of Neurobiology, Yale 
Gerald Edehnan, Nobel Laureate, Scripps Research Institute 
Marcus E. Raichle. Neurologist. Wasliington University 
Steven Pinker, Cognitive Scientist, MIT 

SATERBAY, SEPTEMBER 6 
Healtii Care: 9:30 a.m. 

Susan G. Dentzer. Senior Writer, U.S. News & U oriel Report 
C. Everett Koop, Seruor Scholar, Koop Institute at Dartmoutii 



Philip Kitcher. Professor of Philosophy, UCSD 

Daniel .1. Callahan, Director, Hastings Institute 

Lonnie R. Bristow, Immediate Past President, AMA 

Ruth Purtilo, Director, Center for Health Pohcy and Ethics, 

Creighton Universits- 
William Roper, Senior Vice President, Prudential HealthCare 
Robert G. Evans, Economist. Universitv' of British Columbia 

World Population: 2:30 p.m. 

Michael S. Teitelbaum, Program Officer, Sloan Foimdation 

Thomas Homer-Dixon, Umversit\' of Toronto 

Hania ZIotnik. Cliief, Mortahts- and Migration, United Nations 

Bicentennial Concert: 8:00 p.m. 

Varied program, including a special jjicentennial commission 

SENBAY, SEPTE^IBER 7 
Closing Session: 9:30 a.m. 

S. Marsh Tenney. Professor of Physiology Emeritus, Dartmouth 
Sir David Weatherall, Professor of Medicine, Oxford Universit\- 
Michael S. Brown, Cochair, Bicentermial Symposium 
Heinz Valtin, Chair, Bicentennial Symposium Committee 



Harvard Medical Alumni Bulletin 



Commentary 

by Victoria McEvoy 



I open the recent batch of patient 
complaints from one of our HMOs: 
Mrs. Quill is furious because her pri- 
mary care doctor won't authorize a 
breast reduction with the plastic sur- 
geon that her best friend used. John 
Bellow wants the HMO to pay for his 
son's orthotics, despite the fact that 
orthotics are not a covered benefit. If 
the HMO doesn't agree to pay, he will 
sue for malpractice since the injury 
was never treated properly in the first 
place. Mary Gold is going to switch 
doctors because she called her doctor 
one morning and never got a call back. 
The doctor explains that he never 
received the message. 

I put aside my medical director hat 
and put on my pediatrician hat. "I'll 
deal with those later." Looking for- 
ward to greeting a cherubic three- 
year-old clutching a Barbie doll with 
no hair, I happily resume the role of 
doctor. Thirty minutes later I am 
locked in a battle with the three-year- 
old's mother who insists that amoxi- 
cillin is the wrong drug. 

Some days as the medical director 
of a busy multispecialty group practice 
I feel I am on the field of a Chechen 
war zone — tentatively stepping out to 
take care of patients, deciding that all 
is well, only to be broadsided by 
another missile from an edgy con- 
sumer. Most of us welcome educated 
patients who take responsibility for 
their health care, but consumerism is a 
double-edged sword. 

Some days are great, filled with sat- 
isfying patient interactions: a new dia- 
betic who feels better on insulin, a 
wound that finally heals, or a choco- 
late-stained drawing from a little 
patient who used to cry whenever my 
visage appeared. Other days calls are 
placed to real estate licensing boards 
inquiring how to get a hcense or to 
benefit offices inquiring how long 
until pensions can sustain early retire- 
ment. 



The daily papers mirror this love- 
hate, manic-depressive roller coaster 
that the doctor-patient relationship 
rides as we descend deeper and deeper 
into managed care hell. Hillary's plan 
is starting to look better every day. 

But perhaps it is not surprising that 
patients enter our offices with a skepti- 
cal chip on their shoulders. If I 
believed all that I read I would enter 
an exam room cautiously as well. A 
recent salvo in the New York Times 
from Stephen Cohen (10/10/96) is 
entitled "Should Health Care Come 
with a Warranty?" After jokingly sug- 
gesting that doctors should offer 
money-back guarantees for less than 
satisfying results, he points out that 
perhaps financial incentives should be 
aligned with compassion, kindness and 
dedication. Has it really come to this? 
Do consumers think that without 
financial reward, we will not be kind? 

In an era when patients can now 
"check up" on doctors in the data bank 
by "1-800 let's see if she has a record," 
it is hard not to feel that a line in the 
sand has been drawn. If we were privy 
to the "records" of lawyers, plumbers, 
financial analysts, real estate brokers 
and administrators, doctors would not 
feel so besieged. At times it seems that 
the rights accorded to patients are not 
available to health care providers. 
While patients can complain to patient 
advocates, investigate a doctor's past, 
and dump a doctor on the spur of the 
moment, doctors cannot even sever 
the patient-doctor bond because of 
contractual obligations to HMOs. So 
doctors can be mistreated by their 
patients with no recourse. 

While the pool of people who feel 
sorry for doctors is vanishingly small, 
we certainly are entitled to a brief 
moment of silence to remember the 
once sacrosanct doctor-patient rela- 
tionship. What can be done to rescue 
the core of goodness that prompted 



most of us to pursue a life in the heal- 
ing professions? 

First we need to remember that this 
is not a fight with doctors and patients 
in separate corners. We are on the 
same team, pursuing the same goal, 
and actually have more in common 
than we recognize. Both patients and 
doctors feel the burn of managed care. 

Next we must acknowledge that the 
fee-for-service system was not the 
altruistic, trouble-free machine that we 
like to memorialize. But the baby is 
getting tossed out with the bath water. 
We've got to be pointedly vocal about 
what we're at risk of losing. Long- 
term personal relationships with 
patients have been supplanted by 
revolving door patient panels tainted 
by battles over referrals and HMO rules. 
We need to get some control back. 
We can't let hostile articles go unan- 
swered. We need to show that we can 
manage care in a fiscally and qualita- 
tively sound way. 

We all — doctors and patients — 
need to be part of the solution. 
Physicians must not cede their place at 
the table to administrators and politi- 
cians, and patients should remember 
that most physicians went to medical 
school to become healers. And both 
sides need to renew that special bond 
that takes place in the exam room 
without the HMO preferred drug for- 
mulary, the POS machine, and the bevy 
of health care consultants that are poi- 
soning the sacred trust. 

Victoria McEvoy is the medical director of 
General Medical Associates in Weston, 
Massachusetts, HMS instructor in pedi- 
atrics and a member of the Bulletin edito- 
rial board. 



Spring 1997 



Book Mark 



The E\t of the Artist 
by Michael F. Marmor and 
James G. Ravin 
(Alosby, St. Louis, 1997) 

by Judith and John Dowling 

This dehghtful and informative book 
is written primarily by two ophthal- 
mologists, Michael F. Marmor '66, 
professor of ophthalmology at 
Stanford University, and James G. 
Ravin, clinical associate professor of 
the Medical College of Ohio. The 
book derives in good measure from 
two courses the authors have taught 
for a number of years at the annual 
meeting of the Academy of 
Ophthalmology. One course focuses 
on vision and art and the other on eye 
diseases in artists. Here they join 
forces, and with four collaborators — 
Christine A. Kenyon of the History of 
Art Department, University of 
Michigan; Philippe Lanthony of the 
Centre Hospitaller National 
d'Ophtalmologie des Quinze-Vingts 
in Paris; Jody Maxmin of the Stanford 
Department of Art; and Robert Weale 
of the University of London — they 
provide a wonderful overview of the 
role of visual function in art and how 
eye diseases and the aging eye might 
(and we emphasize might) have 
affected the work of an artist. 

Were El Greco's elongated and 
ethereal figures the result of an eye 
astigmatism as has long been sug- 
gested? How did Monet's cataracts 
affect the coloring in his later paint- 
ings? Is there too much blue in his 
famous water hly paintings because his 
yellow lens was absorbing blue light 
excessively? The book addresses these 
and many other fascinating questions, 
and we won't give away the answers to 
these medical whodunits. We recom- 
mend enthusiastically that the inter- 
ested reader pick up the book and 




learn the answers for themselves, 
which are not always straightforward! 
The book is divided into six parts. 
The first two chapters provide a very 
readable introduction to anatomy and 
physiology of the eye, retina and visual 
system. They also provide an overview 
of the main themes of the book — color 
and contrast in art, for example, and 
the effects on the artist of obvious eye 
deficits, especially those observed in 
the aging eye, including presbyopia 
(far-sightedness), cataracts and color 
deficiency. The other parts of the book 
focus in more detail on one of the 
themes set forth in Part I, and most of 
the chapters describe in some detail 
the work and eye problems of a promi- 
nent artist. Part n is entitled "The 
Problem of Focus" and its three chap- 
ters are devoted to Renoir, EI Greco 
and Euphronious. The latter artist 



may be unfamiliar to many: he was a 
pioneer in red-figure painting in 
Greece, working about 500 B.C. 

Part III discusses "Light Versus 
Dark" and describes how border 
enhancement — the Mach Band phe- 
nomenon — has been used throughout 
the ages, particularly by Asian artists, 
to increase contrast, lightness and 
darkness in a painting. The second 
chapter in this section argues that the 
light in which a painting was painted is 
as critical as the light in which it is 
viewed, and they must be consonant. 

Part r\^ focuses on color and its four 
chapters emphasize the work of four 
artists — Turner, Meryon, van Gogh 
and Seurat. Charles Meryon is another 
artist perhaps unfamiliar to many. He 
had a color vision defect — probably 
protanopia or deuteranopia (red or 
green blindness) — ^which he recog- 



10 



Harvard Medical Alumni Bulletin 



nized early in his career and caused 
him to give up oil painting and turn to 
etching. Part v, on "Perspective and 
Illusion," presents two essays: one on 
perspective and its use, or lack of use, 
through the ages, and the second on 
illusions and optical or op art. That 
visual perception is reconstructive and 
creative has long been recognized. 
Artists, particularly the op art artists 
and of course M.C. Esher, have long 
taken advantage of this phenomenon, 
i.e., what we perceive is based on 
imperfect information transmitted 
from the eye to the brain. Using this 
information and visual memories, our 
brains try to construct a coherent and 
logical precept. But the visual system 
can be confounded, as happens with 
visual illusions, and many artists have 
explored these effects. 

The final section is the longest of 
the book. It consists of six chapters, 
each one devoted to a single artist: 
Monet, Cassatt, Pissarro, Degas, 
Munch and O'Keeffe. These chapters 
provide medical histories of the artists, 
particularly their ophthalmic histories, 
and the treatments then available to 
deal with their problems. It further 
describes the success of the therapies 
(or lack thereof), and the apparent 
effects of their maladies on their art, 
with an emphasis on how their works 
changed over the years as they aged or 
experienced eye diseases. 

The book is lavishly illustrated with 
190 figures, 120 of which are in full 
color. The reproductions are excellent 
and the publisher should be compli- 
mented on the quality of the reproduc- 
tions and the book in general. 

One of the great strengths of the 
book is the discussion throughout of 
many visual and psychological phe- 
nomena. The reader is introduced in a 
clear fashion to current ideas on color 
blindness, retinal and cortical process- 
ing of visual information, color mix- 



ing, perspective, visual texture, visual 
illusions and, of course, Mach Bands. 
An entire chapter, as well as consider- 
able discussion in one of the introduc- 
tory chapters, is devoted to Mach 
Bands and not only is it shown clearly 
how artists over the ages have 
employed this phenomenon to 
enhance edges and borders, but also 
how Renoir purposely diminished con- 
trast along the borders of his figures to 
soften his images. 

The Mach Band phenomenon is 
attributed to Ernst Mach, the 1 9th 
century philosopher and psychologist, 
but this effect was known long before 
Mach's time. Leonardo da Vinci 
described the phenomenon very 
clearly in the i6th century: "The bor- 
der of a vertical rod will appear very 
dark against a white field, and against a 
dark background it will appear 
brighter than any part of the rod, even 
though the light striking the latter is 
equally bright all along" (see R. 
Weale, Discovery of Mach Band, 
Investigative Ophthalmology and Visual 
Science, 18, 652-654, 1979). And, of 
course, Chinese painters exploited 
Mach Bands in their brush paintings 
some 1,300 years before da Vinci, 
beginning in the second century A.D. 

Other aspects of considerable inter- 
est are pertinent historical anecdotes 
sprinkled throughout. In the chapter 
on Turner and his use of color is a 
description of Goethe's views on color 
and the fact that Goethe — a contem- 
porary of Turner's — debunked 
Newton's views proposed nearly a cen- 
tury before that white light is a mix- 
ture of all colors and that light is 
corpuscular. Goethe wrote a book on 
color called Theory of Colours that is 
largely forgotten today, but Turner 
owned this book, made numerous 
notes in it, and was undoubtedly influ- 
enced by it. 

As we age, many changes take 



place, not only in our ability to see well, 
but to carry out skilled tasks. Artists are 
not exempt from these changes and an 
important theme in the book is how the 
works of a particular artist vary over time. 
How much of such change can be attrib- 
uted to age and how much to an evolu- 
tion of style? In some cases, aging effects 
can be claimed — coarser brush strokes, 
color abnormalities, and a lack of detail 
in a work. And sometimes, severe visual 
defects have led artists to alter the way 
they worked or even the medium in 
which they worked. As Georgia O'Keeffe 
lost her high acuity vision, probably 
because of macular degeneration, she 
employed a surrogate to help paint her 
pictures. Later she left painting alto- 
gether and turned to sculpture. Matisse 
turned to paper cutouts when his vision 
failed to the point that he could not paint 
and Degas, like O'Keeffe, turned to 
sculpture. 

In sum, this book is a gold mine of 
fascinating historical and medical infor- 
mation, and it provides superb insights 
into the works of a number of the world's 
famous artists. For anyone interested in 
vision and art, this book is a must. 

Judith F. Dowling owns the Judith Bowling 
Asian Art Galleiy in Boston, which special- 
izes in Japanese art. John E. Dowling is 
Maria Moors Cabot Professor of Natural 
Science and professor of ophthalmology (neu- 
roscience), Harvard University. The 
Dowlings are also masters ofLeverett House 
at Harvard. 



Spring 1997 



II 



On the Road 
to Reform 



by Arnold Epstein 




The federal failure to 
reform the health care 
system merely transferred 
responsibility to the 
private sector and the 
states. 



Just over four years ago some 500 
federal health care bureaucrats and 
private sector health care experts filed 
into the Executive Office Building in 
Washington, DC and began a three- 
month sprint to develop federal legis- 
lation that aimed at comprehensive 
health reform. Their goal was to 
establish universal coverage for all 
Americans and drastically revamp a 
health care system that had grown to 
encompass one-seventh of our econ- 
omy. That effort and the long con- 
gressional struggle that ensued came 
to naught. Yet its final demise 20 
months later did not signal the tri- 
umph of the status quo, but rather a 
new era of health reform orchestrated 
by the private sector and the states. 

Everyone should be able to recall 
the horrors painted by opponents of 
national health reform during the 
media campaign of 1993 and 1994. If 
reform legislation passed, fee-for-ser- 
vice medicine would die. All 
Americans would be forced to enroll in 
HMOs and other variants of managed 
care. Eree choice of provider would 
become a relic of the past, and 
rationing and restricted benefits would 
become commonplace. 

Sponsors of health reform had an 
alternative set of predictions, no less 
dire. Without federal legislation, the 
number of uninsured individuals 
would grow inexorably. Medical cost 
escalation would increase to the point 
that it would threaten the competitive 
ability of American business. Medicare 
and Medicaid would drain federal and 
state budgets to the point of insol- 
vency. 

Today we still cannot assess the 
ultimate results of private health care 
reform. But already there have been 
enough changes to describe its charac- 
ter and predict its path. 

Competition and Consolidation 

Many of the changes feared by Harry 
and Louise and their counterparts sit- 
ting around America's dinner tables 
have already come to fruition. Most 
Americans are facing a reduced choice 



Harvard Medical Alumni Bulletin 



of health plan and practitioner. Among 
medium-sized employers, more tiian 
half are offering their workers only 
one health plan. According to a recent 
KPMG Peat MarwickAVajme State 
University survey, nearly three-quar- 
ters of American workers are now 
enrolled in managed care plans, up 
from 51 percent in 1993. 

The characteristics of managed 
care organizations, which provide care 
to most Americans, have also changed. 
For-profit managed care organizations 
now account for the majority of the 
managed care market, whereas a 
decade ago they enrolled just over 25 
percent. 

Competition has also had a large 
impact on hospitals and practitioners. 
Many hospitals across the country 
have closed or consolidated. More 
than half the nation's hospitals are now 
part of multi-hospital firms. The con- 
solidation in Boston that created 
Partners HealthCare System and pro- 
duced the merger between the Beth 
Israel Hospital and Deaconess 
Hospital is mirrored across Massachu- 
setts where, according to the Massa- 
chusetts Health Data Consortium, the 
number of hospitals has decreased 
from 95 in 1992 to 84 today. Acute- 
care hospital patient days dropped 
from 5.5 milhon in 1992 to 4.3 million 
in 1995. 

Ironically, physicians have been 
both embattled by managed care and 
increasingly involved in its manage- 
ment. Selective contracting by man- 
aged care plans, termination of 
physicians' contracts for economic 
rather than clinical reasons, and "gag 
rules" — contractual requirements that 
forbid physicians from advocating 
treatments for which the HMO will not 
approve payment, or from disclosing 
pajmients they may receive as a conse- 
quence of denying services to their 
patients — have been strongly opposed 
by individual physicians and their pro- 
fessional associations. 

At the same time, physician-spon- 
sored organizations (PSOs) have 
become a major weapon of organized 



medicine. PSOs, which might be 
likened to the service arm of an PiMO, 
can provide comprehensive medical 
services and contract directly with 
employers, eliminating the HMO mid- 
dleman. Three-quarters of the 50 
state medical societies are now plan- 
ning to establish physician-sponsored 
organizations, reported Thomas 
Bodenheimer '65 in the November 21, 
1996 issue of the New England Journal 
of Medicine. 

One healthy byproduct of the more 
competitive marketplace has been the 
disruption of dramatic medical cost 
inflation that went unabated for many 
years. Between 1985 and 1991, for 
example, national health care expendi- 
ture increased at a fairly steady rate, 
averaging 10. i percent annually, 
whereas in 1993 and 1994, the rate of 
increase dropped to 7 percent and then 
6.4 percent. 

The changes in the private sector 
have been even more dramatic. 
According to a recent national survey 
of employees with ten or more work- 
ers by Fouter Higgins, a benefits con- 
sulting firm in New York, health 
benefit costs increased only 2.1 per- 
cent in 1995, after a decline of i.i per- 
cent in 1994. Between 1988 and 1992 
employees' health benefit costs 
increased nearly 1 5 percent annually. 

Many economists believe that this 
change in inflationary trends could 
never have been achieved by the fed- 
eral government. Decisions to close 
health care facilities are particularly 
difficult to legislate because of 
entrenched political interests, not to 
mention a general mistrust of govern- 
ment among Americans. Consider the 
special legislative rules developed to 
govern the closing of military bases. 
Closing hospital facilities would likely 
be even more difficult. Employers and 
other large purchasers are able to insist 
on changes that elected officials could 
never even propose. 

Of course, reduced cost inflation in 
and of itself is not a universal blessing. 
Certainly lower rates of increase in 
medical costs are a boon for American 



business. But although the hospital 
sector is in the midst of radical reengi- 
neering, thus far hospital margins have 
remained at or above historic levels. 
Physicians' incomes, on the other 
hand, have declined. National data 
from the American Medical 
Association showed a decrease in 
physicians' incomes in 1994, breaking 
a long-term trend. Physicians' average 
net income had been rising steadily 
during the last decade except for a 
one-year break in 1990. Average earn- 
ings increased from $154,800 in 1985 
(1994 dollars) to $195,300 in 1993 
before falling nearly $9,000 to 
$186,600. Data from California, where 
the transition to managed care is 
among the most advanced, show even 
larger reductions in some doctors' 
earnings. Many predict that these 
trends will become even more pro- 
nounced as managed care changes pat- 
terns of use for medical services and a 
glut in specialists develops. 

The HMO Backlash 

Some who decry the recent changes in 
the medical delivery system believe 
that we have adopted the Clinton 
vision of managed care but without 
consumer protections. Regulation of 
HMOs is largely state based. Consumer 
protections have traditionally been 
weak. The regulations for HMOs origi- 
nally adopted in most states focused on 
assuring fiscal stability and basic mini- 
mal protections, such as appeals proce- 
dures. Most of the rules were 
developed over a decade ago when 
HMOs cared for a much smaller pro- 
portion of the population and the large 
majority of HMOs were not-for-profit 
organizations that were much less 
aggressive and threatening than 
today's highly competitive managed 
care organizations. 

Now a backlash is spreading across 
the country. Physicians decry their loss 
of autonomy as well as the paperwork 
and rules that impede them from pro- 
viding care efficiently. Patients fear 
that financial disincentives to provid- 
ing needed medical services will 



Spring 1997 



13 



reduce quality of care in managed care 
organizations. The emergence of PSOs, 
the frequent reporting of HMO horror 
stories in the lay press, and the adop- 
tion of a wide range of new state and 
federal legislation are all evidence of 
this backlash. 

In 1996 alone, more than 30 states 
passed legislation to regulate HMOs 
and strengthen consumer protections. 
Prohibitions against "gag rules," guar- 
antees of self-referral to specialists 
(most often gynecologists), and 
requirements for HMOs to pay for 
emergency care on the basis of a "pru- 
dent layperson's" definition of a med- 
ical emergency (a definition much 
broader than that used by most HMOs) 
are among the most common sorts of 
regulatory relief. Perhaps the most 
controversial legislation passed both 
by the federal government and the 
majority of states is the prohibition of 
so-called "drive-by deliveries," a law 
that requires HMOs to cover the cost of 
at least 48 hours of postpartum hospi- 
tal care. 

Changes in Quality of Care 

Despite well-warranted concerns 
about incentives for managed care 
organizations to skimp on care, there 
is little evidence to suggest that care 
has deteriorated substantially. There is 
even reason to be hopeful that the play 
of competitive market forces will sub- 
stantially benefit some groups of con- 
sumers. The Health Employers Data 
and Information Set (hedis) and other 
batteries of quality indicators have 
become common. Standardized mea- 
sures of quality are used to compare 
quality of care in different settings, 
identify best practices, target clinical 
areas for quality improvement, and 
guide better purchasing decisions by 
large employers. Although tools such 
as HEDIS are currently crude, broad 
effort — supported by the government, 
private foundations, health plans and 
purchasers — is under way to improve 
them and make them more relevant to 
special populations, such as those 
enrolled in Medicaid and Medicare. 



"Concerns about the 
large number of 
uninsured have lost 
their urgency^ but 
the problem has not 
disappeared. " 



Even with crude indicators, publi- 
cation of standardized comparative 
data can spur quality improvement. 
One example, based at hospitals rather 
than health plans, is the New York 
state experience with publication of 
risk-adjusted mortality data for 
patients undergoing coronary artery 
bypass graft surgery. These sorts of 
data have been collected annually since 
1989 on every cardiac surgeon and 
hospital in the state and released pub- 
licly since 1991. The statistics have 
been in such widely read newspapers 
as the New York Times and Newsday. 

The publicity has had a consider- 
able impact. Hospitals in the state have 
targeted coronary artery bypass graft 
surgery for quality improvement 
efforts and instituted technical 
improvements in the procedures. 
Physicians who performed this sort of 
surgery infrequendy and had poor 
mortality statistics have been encour- 
aged to discontinue practice. 
According to New York state statistics, 
mortality after coronary artery bypass 
surgery decreased by 2 1 percent and 
risk-adjusted mortality decreased by 41 
percent during the four-year period 
between 1989 and 1992. Although 
mortality statistics after bypass surgery 
also improved nationally during this 
period, the changes in New York state 
were significantly greater. 

Competitive markets have also 
stimulated a host of quality improve- 
ment efforts in health plans through- 



out the country. Employer groups are 
applying continuous quality manage- 
ment techniques and negotiating with 
health care providers to demonstrate 
measurable improvement in quality of 
care. Innovators such as the Inter- 
mountain Health System in Utah have 
demonstrated that important improve- 
ments in quality can go hand-in-hand 
with reduced costs. Although skeptics 
will argue that advances to date have 
been more smoke than fire, the level of 
activity at health plans across the 
country is broad enough to suggest 
that market forces can promote higher 
quality as well as lower costs. 

Disadvantaged Populations 

Private health reform may result in 
greater value for large segments of the 
American population, but its impact 
on many disadvantaged persons is 
unclear. Two groups, those insured by 
Medicaid and those who are unin- 
sured, are particularly vulnerable. 

The success of the private sector in 
using managed care to control costs 
together with accelerating budgetary 
pressures have prompted many states 
to convert their Medicaid program 
from traditional fee-for-service cover- 
age to managed care. The number of 
Medicaid beneficiaries enrolled in 
managed care increased from 2.5 mil- 
lion in 1 99 1 to 13.3 million in 1996, 
according to the Office of Managed 
Care of the Health Care Financing 
Administration. This group comprises 
approximately 40 percent of the 
Medicaid population. The fastest 
growth has been in fully capitated 
health plans, which now provide care 
for approximately 70 percent of the 
Medicaid managed care market. 

The use of capitation for Medicaid 
enrollees has been controversial. 
There are potentially strong advan- 
tages in converting Medicaid to 
managed care, however. Greater inte- 
gration of services provided by man- 
aged care provides opportunity for 
improving the care of individuals with 
multiple chronic conditions. Use of 
managed care also provides an avenue 



14 



Harvard Medical Alumni Bulletin 



for specifying accountability and set- 
ting performance goals that was 
impracticable in the fee-for-service 
system. 

Nevertheless, many worry. As with 
privately insured persons, health plans 
including the Medicaid population 
have a financial disincentive to provide 
all needed medical services. Most plans 
have little experience caring for disad- 
vantaged populations, and many are 
unprepared to meet the characteristic 
challenges of this population: poor 
nutrition, illiteracy, and problems with 
transportation and communication. 
Medicaid beneficiaries may also have 
particular difficulty navigating the 
complex bureaucratic structures of 
managed care organizations. 

The other group that seems threat- 
ened by the growth of managed care is 
the uninsured. In the last four years 
concerns about the large number of 
uninsured persons in the country have 
lost their political urgency, but the 
problem has certainly not disappeared. 
Between 1988 and 1994 four million 
fewer people were covered by employ- 
ment-based health insurance. 
Although expansion in Medicaid par- 
tially compensated for the loss of 
employment-based coverage, the num- 
ber of uninsured individuals has con- 
tinued to grow. Today approximately 
40 million Americans lack health 
insurance at any point in time; another 
29 million individuals are underin- 
sured for the consequences of serious 
illness they may suffer. 

During the national health reform 
debate there was substantial contro- 
versy about whether the number of 
uninsured persons in our country con- 
stituted a crisis. Whether a crisis or 
not, there is appreciable evidence that 
uninsured persons are less likely to see 
health care providers in a timely man- 
ner, and are more hkely to be hospital- 
ized for conditions that could have 
been effectively treated by outpatient 
care. In addition, uninsured persons 
generally receive fewer medical ser- 
vices when they are seriously ill and 
have worse health outcomes. 



The growth of Medicaid managed 
care ironically may both improve care 
for Medicaid enrollees while destabi- 
lizing the safety net that has anchored 
care for the uninsured. For many years 
inner city physicians, academic health 
centers, and neighborhood health cen- 
ters have been the cornerstone of care 
for the Medicaid population and the 
uninsured. With the growth of 
Medicaid managed care, this network 
is being replaced by a new combina- 
tion of providers that includes both 
commercial HMOs and health plans 
that serve predominantly Medicaid 
enrollees. 

Many health plans participating in 
Medicaid managed care have incorpo- 
rated traditional safety net providers. 
However, there are still fears that 
many neighborhood health centers, 
inner-city physicians, and municipal 
hospitals that have traditionally served 
the Medicaid population may be 
unwilling to join managed care organi- 
zations or unable to meet their creden- 
tialling requirements. Reduction in 
Medicaid revenues for these providers 
coupled with market pressures and 
price competition will make it increas- 
ingly difficult for these providers to 
provide the charity services that now 
underpin care for the indigent and 
uninsured. 

What Happens Next 

Although the failure of the Clinton 
administration to achieve comprehen- 
sive health reform may have seemed at 
the time like a national vote for the 
status quo, today it seems clear that 
federal failure to reform the health 
care system merely transferred much 
of the responsibility to the private sec- 
tor and the states. Federal legislation 
and the regulations developed by the 
Health Care Financing Administration 
and other federal health care agencies 
will always be important. But increas- 
ingly the focus of health policy will lie 
in the purchasing decisions of large- 
scale employers, the marketing and 
managerial decisions of managed care 
organizations, and the administrative 



rules and legislation passed in 50 dif- 
ferent states. 

The next few years will be critical, 
as private health reform is still very 
much a work-in-progress. Decisions 
made in the evolving medical market- 
place will determine whether conver- 
sion to managed care leads to 
integrated medical services, better 
quality and more efficient care, and 
whether managed care disrupts the 
safety net that now anchors care for 
the Medicaid population and the unin- 
sured. 

Perhaps the biggest uncertainty 
involves the uninsured. Not only is 
their number likely to grow with cur- 
rent market forces, but there is little 
sign that the problems of their medical 
care are likely to resolve on their own. 
Federal and state legislation to reduce 
the number of uninsured incremen- 
tally seems likely. And, ironically, 
reductions in employer-based coverage 
will probably increase the proportion 
of middle-class uninsured, thus trans- 
forming the uninsured into a much 
more powerful political constituency. 

The evolving balance between 
these forces and the concurrent 
changes in the health care delivery sys- 
tem will ultimately determine whether 
the problem of the uninsured contin- 
ues to fester quietly or resurfaces as a 
major dilemma. In the past we have 
been able to improvise, relying on a 
threadbare safety net to provide ade- 
quate, if not optimal, care to the unin- 
sured. In the future we may be 
prompted again into formulating a 
more deliberate national policy. ^ 

Arnold M. Epstein, MD, MA is chainnan 
of the Hm-vard School of Public Health V 
Department of Health Policy a?id 
Maiiagevtent, HMS Professor of Medicine 
and Health Care Policy, and an internist 
in the Division of General Medicine at 
Brigham and Women 's Hospital. During 
1993-94 ^^ ivorked in the White House, 
where he served as a policy advisor on 
health care, particularly on issues related 
to quality ?nanagement and academic 
health centers. 



Spring 1997 



15 



Two 

Heads 

Are 

Better 

Than 

One 



by Joshua Sharfstein 



For months I read of merger 
mania in the health care industry with 
only passing interest. So what if hospi- 
tals, doctors and managed care plans 
were pairing up like animals in line for 
Noah's Ark? 

As a medical student and occasional 
patient, I had plenty more to worry 
about than the latest billion dollar 
deal. 

Until three months ago. 

That's when I opened my mail to 
find a memo from my dean entitled 
"Merger of Boston Medical Schools." 

"This merger is our last attempt to 
protect our share of an increasingly 
competitive market," the memo read. 
"It will require consolidation at all lev- 
els of administration, teaching and 
health care delivery. As a fourth-year 
medical student at Harvard, you will 
merge with a fourth-year student at 
Boston University. We have tried to 
merge students with similar interests 
and of similar heights, although this 
was not possible in all cases. Please call 
the registrar if you have any ques- 
tions." 

My hands trembled as I put down 
the notice, and my mind raced. Merge 
with another medical student? Was 
that humanly possible? 

Then I laughed. The deans must 
have gotten together and hatched a 
prank. (But was that humanly possi- 
ble?) 

I ran to a phone and dialed. 
"Boston Medical Schools Registrar!" a 
woman answered cheerfully. "How 
may I help you?" 

"About the merger," I asked. 
"Why?" 

"Cheaper, bigger, stronger," she 
said. 

"When?" 

"Monday," she answered. "Thank 
you for calling." 

I put down the phone in shock. 
Faced with an uncertain future, pushed 
and pulled by forces out of my control, 
I began to rationalize. 

Hey, no more lonely nights on call 
alone in the hospital, I told myself. 
Twice the brainpower might lead to 



higher scores on my standardized tests. 
Hey, would I only pay half the tuition 
bill? 

Now I was starting to cheer up. 
Nothing like the prospect of lower 
prices to stifle opposition. I dialed the 
registrar back. 

"Boston Medical Schools." 

"Tuition?" I asked. 

"The merger saves us money, not 
you," she said. "No different from any 
merger these days." 

"Well, what ifit doesn't?" I 
demanded, giving way to anger. "Or 
what if the merger turns out to be bad 
for doctors? Or patients?" 

"If this merger is not good eco- 
nomics, everything will change again," 
she assured me. "But if it's not good 
for doctors, where else are they going 
to go? And if it's not good for patients, 
who'll ever know?" 

I had no answer. "What if I 
promise to study twice as hard? Then 
do I have to merge?" 

She responded stiffly. "If you don't 
understand how financial pressures are 
transforming the health care system, 
that'll be a great topic to discuss with 
yourself after you've merged. And 
please don't call again if it's just half of 
you." 

That was three months ago. In the 
time since, I have followed news of 
mergers with a lot more interest. The 
reports generally focus on the execu- 
tives, stock prices or the total number 
of "lives" covered by the mega-plan. 
But now I see that it's the little per- 
son — the patient, the medical student, 
the hospital worker — ^who has to live 
with the changes. 

Being part of a merger has finally 
opened my eyes. All four of them. ^ 

Joshua Shaifstein '96 is a first-year 
pediatrics resident at Boston Medical 
Center aiid Children's Hospital. This first 
appeared in the Boston Globe on October 
21, 1996. 



16 



Harvard Medical Alumni Bulletin 



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Spring 1997 



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17 



Competition 
Among Friends 



hy Ellen Barlow 



It was an announcement that 
caused a "tectonic lurch" felt by all of 
medical Boston, reported one local 
newspaper. When Massachusetts 
General and Brigham and Women's 
hospitals announced at the end of 1993 
that they were forming an alliance, 
shock waves were felt well beyond 
Boston. For if these Harvard titans felt 
the economic imperative to form an 
alliance, then who could afford not to 
act? Locally it portended a rearrange- 
ment of the Harvard medical land- 
scape that has carved up the major 
teaching hospitals into two, possibly 
three separate health care systems. 
Though it remains to be seen if 
bigger is indeed better, the major 
Harvard teaching hospitals are now set 
on competitive courses, vying for the 
largest share of the patient market. 
Once one group got together, the oth- 
ers had to do something or get left in 
the dust. And now, as that dust is set- 
tling in the Longwood medical area, 
the major teams have been formed: 
Partners HealthCare System, the par- 
ent company of MGH, BWH and the 
North Shore Hospital; CareGroup, 
the parent of the merged Beth Israel 
Deaconess Medical Center, Mt. 
Auburn Hospital, and four hospitals of 
the Deaconess's former Pathway 
Network; and Children's Hospital, 
which is remaining independent while 
still talking with the other systems and 
amassing its own pediatric services sys- 
tem. 



Nor are these the only changes 
among Boston's teaching hospitals. In 
July 1996 Boston University Medical 
Center merged with Boston City 
Hospital, ending a 132-year tradition 
of direct municipal health care for the 
poor, although the hybrid Boston 
Medical Center will receive city subsi- 
dies to provide accessible health care. 
Then in December 1996, a collective 
sigh of relief could almost be heard 



among the Boston medical community 
when Tufts-New England Medical 
Center, after much shopping around, 
finally chose Lifespan — a nonprofit 
chain based in Providence, Rhode 
Island, affiliated with Brown 
University — over Columbia/UCA 
Healthcare Corp., a for-profit chain, 
which has been prowling for a Boston 
tertiary care facility. 



The first alliance: Mass. 
General and Brigham and 
Women's. 



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Harvard Medical Alumni Bulletin 



Massachusetts has one of the high- 
est percentages of its population 
enrolled in HMOs — 43 percent, or of 
those insured, 60 percent — so man- 
aged care is the most often cited insti- 
gator of revolutionary change here. 
With more and more payments being 
capitated and price-competitive con- 
tracts being struck, costs have had to 
be contained. Lengths of stay have 
dropped, beds have been empty, and as 
more treatment has been shifting to 
outpatient settings, hospitals have been 
left with excess and expensive technical 
capacity. Those that had built heavily 
were caught short of repayment capi- 
tal. And just as federal grant money for 
research was getting scarcer, teaching 
hospitals with research missions, which 
traditionally have used clinical monies 
to fill in the research granting gaps, 
were facing their own shortfalls. 

Dean Daniel C. Tosteson '48 was 
aware that these forces were producing 
irrevocable change and in January 



1993 convened representatives (the 
CEO, the chairman of the board and a 
key physician) from each of the five 
major teaching hospitals (MGH, BWH, 
BI, Deaconess and Children's) to dis- 
cuss the future of Harvard medicine 
and how they might all work together. 
Six months into the discussions, the 
MGH and BWH decided to talk on their 
own, leaving some hard feelings in 
their wake. 

The story of what has happened 
would be different if told by faculty 
physicians, different if we were to 
speculate how Massachusetts patients 
might fare as a result. But this is the 
story of where six of the Harvard 
teaching hospitals are going and how 
they got there, through the eyes of 
their chief executives, the ones who say 
they are taking these new risks because 
the risk of not doing anj^hing could 
mean the demise of their historical 
missions. 



Choosing Partners 

Partners was not the first hospital con- 
solidation in Massachusetts, but it was 
the kingpin of the teaching hospitals. 
In fact the partnership was forged in 
part to take a leadership role in reorga- 
nizing health care delivery. It repre- 
sented two hospitals coming together 
not because they were financially des- 
perate but rather from a position of 
relative strength. 

The two hospitals — despite being 
cross town from one another and hav- 
ing very different medical "cultures" — 
agreed to affihate to achieve 
economies of scale and to increase 
their share of the patient-care market 
by creating what they call a "physi- 
cian-driven integrated health care 
delivery system." The centerpiece of 
the Partners system is a network of 
750 primary care physicians (the goal 
is to have 1,000 by 2001), who are the 
ones making decisions about care and 
where in the network continuum their 
patients should be at any given time: in 
tertiary, community, or rehabilitation 
hospitals; in nursing homes; or at 
home with home health care. 




"\^"e saw ourselves as two vigorous 
hospitals, with excellent medical staffs, 
each attracting excellent house staffs, 
and each either number one or num- 
ber two in the nation among indepen- 
dent hospitals in attracting federal 
grant money," recalls H. Richard 
Nesson, AID, president of Partners and 
B\\'H. His counterpart in negotiating 
the alliance deal was J. Robert 
Buchanan, MD, then general director 
of MGH, who retired soon after the 
arrangement was forged. "Dr. 
Buchanan and I knew each other well 
and had vaguely talked about doing 
something together before, an 
unheard of thing." But in the final 
analysis, the question for them came 
down to: why compete and erode each 
other further, when we could collabo- 
rate? 

The intention was never to inte- 
grate both hospitals into one building 
or fully merge in the legal sense, which 
would have meant merging their 
names into something new. They both 
wanted to keep their institution's own 
names, "our best brand names." After 
all, MGH, founded in i8i i, is the oldest 
hospital in New England. There are 
some things you shouldn't tinker with. 

The Brigham is a newer entity — 
itself representing a merger in 1976 of 
the Peter Bent Brigham, the Robert 
Breck Brigham, the Free Hospital for 
Women and Boston Lying-in. 
Nesson, who had just started at the 
Peter Bent Brigham, oversaw those 
changes, and attributes the confidence 
he had to sit down at the table and 
negotiate with MGH to that experience, 
knowing that something could be 
worked out. 

From Nesson's point of view, the 
meetings of the five teaching hospitals 
that the dean was sponsoring were not 
getting anywhere. "It failed with a 
large group of people to move forward 
toward substantial rearrangement 
despite all kinds of meetings." He and 
Buchanan decided to continue talking 
on their own and so informed the 
dean. Four people from the Brigham 
(including Eugene Braunwald) and 



As the dust is 
settling in the 
Longwood medical 
area^ the major 
teams have been 
formed. 



four people from the General (includ- 
ing Gerald Austen '55), plus legal 
experts, worked together on the deal 
and then scheduled a retreat on 
December 8, 1993. "Even I didn't 
know before the retreat that the group 
would decide to take a meaningful step 
and not a half-step at getting 
together," says Nesson. When the 
retreat was over, the news broke. 

On the Friday before the retreat 
Samuel Thier, MD, then president of 
Brandeis, accepted the job as CEO of 
the MGH. He was first the president 
and then, in July 1996, chief executive 
officer of Partners. 

When asked by a reporter one year 
later what it was like to take the helm 
of these hospitals at such a pivotal 
point, Thier responded, "It's one of 
the only jobs I can imagine that makes 
a university presidency look like play- 
ing in a sandbox." Thier had "cut his 
teeth" at Mass. General, from intern 
to staff member, so he was seen as one 
of the family. But he had also been on 
the staffs of Penn, Yale and Hopkins, 
and had been president of the Institute 
of Medicine of the National Academy 
of Sciences, so he also had the "sense 
that other places were capable of car- 
rying out the academic mission." He 
came here "convinced that what Dick 
and Bob and the trustees had done 
made sense. The MGH would be in 
trouble if it didn't adjust." 

The MGH staff were in shock and 
wondered why they needed to do this. 



"If you sat down with people, intellec- 
tually they knew this was the right 
thing and had been done thoughtfully, 
but emotionally they wondered if we 
really needed someone else's help," 
says Thier. "Despite all the anxiety, 
when they calm down, they realize 
they are joined with an equal." 

So what exactly has resulted from 
this affiliation? In addition to creating 
a network of primary care physicians 
called Partners HealthCare, Inc., they 
have: 

• achieved a savings of $150 million 
toward a goal of $325 million over the 
next several years. 

• consolidated and centralized 
administrative departments, including 
finance, treasury management, human 
resources, community benefits, real 
estate and planning, information sys- 
tems and telecommunications, bio- 
medical engineering, materials 
management, and general counsel. 

• consolidated or cut back residencies 
and fellowships 20 percent; of the 19 
common residencies, 8 are fully inte- 
grated. 

• reduced the number of beds 20 per- 
cent (though recently volume has 
increased). 

• signed on a third partner. North 
Shore Medical Center, in September 
1995. 

• centralized some service laborato- 
ries, with radiology next. 

Partners is bringing adult oncology 
under one umbrella with Dana-Farber 
Cancer Institute, and they are slowly 
consolidating other clinical depart- 
ments as opportunities arise. Since the 
two chiefs of orthopedics are retiring, 
they are now seeking a single chief to 
head both. "Neurology spontaneously 
came together," said Thier, and next 
to be combined is psychiatry. Added 
Nesson: "We're trying to do this with 
the least disruption possible." 

Thier notes that it is important to 
remember that these two hospitals did 
not in fact have much overlap in the 
patient populations and the areas they 
served. They were criticized for not 
taking consolidation seriously when 



20 



Harvard Medical Alumni Bulletin 



right after the affihation agreement 
was announced, MGH revealed that it 
was opening an obstetrics service. 
"bwh dehveries were down from 9,000 
to 8,000 per year and our survey 
showed an overlap population between 
the two hospitals of only 5 percent," 
says Thier. A MGH obstetrics unit 
would draw new patients, they figured, 
people who wouldn't have crossed 
town to the Brigham and would other- 
wise have been lost from their system. 
"This was a whole new region to open 
up," says Thier. "In fact, this year the 
combined deliveries will be more than 
10,500 — a 25-30 percent increase. 
Consolidation and integration of ser- 
vices cannot be made too simplistic." 

A month before Thier was to 
accept the MGH job in 1993, he was 
asked to speak on the fate of academic 
medicine at the annual meeting of the 
Association of American Medical 
Colleges. Rather than looking at the 
future as something fated, he chose 
Chekhov's play "The Cherry 
Orchard" as a framework for discus- 
sion. In the play a family must decide 
whether to keep or sell their cherry 
orchard to save their home, but due to 
indecision, their orchard is chopped 
down and they lose their home. Asked 
to comment how this reference applies 
now, Thier chuckles and says, "Well, 
we avoided chopping down the cherry 
orchard." 

Formation of CareGroup 

Clearly the direction MGH and BWH 
took left the other teaching hospitals 
in a quandary. No one institution 
alone could offer the breadth and 
depth of Partners. One can imagine 
the amount of time that has been spent 
the past few years at other hospitals 
behind closed doors with consultants, 
legal advisors and suitors of every sort. 

At the Beth Israel Hospital, 
Mitchell T. Rabkin '55 had to consider 
what to do. "The joining of the 
Brigham and the General created a 
massive institution that in many 
respects overshadowed the Bl. 
Although we certainly ranked right up 



there in terms of clinical care and 
maybe ahead in terms of warmth and 
personalization of care, the intellectual 
enterprise was by no means compara- 
ble." 

The Deaconess felt similarly and 
being even smaller, felt it even more 
acutely. The BI and Deaconess had 
specialties that were complementary, 
and they were geographic neighbors. 
"It looked like joining together we 
could really round out and develop a 
merged institution of reasonable 
breadth and depth," explains Rabkin. 
"Together we could basically pony up 
to the bar at Harvard Medical School 
and not be the 97-pound weakling that 
everybody kicks sand onto." 

After months of planning, the hos- 
pitals announced their formal merger 
in October 1996, forming the Beth 
Israel Deaconess Medical Center. 
Mount Auburn Hospital was also part 
of the merger, and including the four 
hospitals that had been part of the 
Deaconess's Pathway Network — N.E. 
Baptist, the Deaconess-Nashoba, the 
Deaconess-Glover and the Deaconess- 
Waltham — there are now six hospitals 
under the parent corporation called 
CareGroup. They celebrated the 
merger on the medical school's 
Quadrangle, with congratulatory com- 
ments from Dean Tosteson and 
Senator Edward M. Kennedy, among 
others. 

It appeared to take an impressively 
short time to merge the identities of 
the BI and Deaconess. New signs on 
Brookline Avenue went up right away. 
Phones were answered in offices 
throughout both hospitals: Beth Israel 
Deaconess. Medical staff quoted in 
newspapers were attributed correctly. 
The logos of the two were imagina- 
tively coalesced to form one. This is all 
the frosting, of course, and the rest of 
the hard work of merging is under 
way. 

"We have to take this system of 
ours and try to develop it into one that 
encompasses a large geographic area, 
with community hospitals and doctors 
in the community, and work it essen- 



tially to the advantage of these local 
doctors and local hospitals," says 
Rabkin. He points out that there has 
been a revolutionary reafization on the 
part of teaching hospitals, which have 
always been focused on the acute 
episode of care: doors swing open in 
the emergency unit, a complicated case 
comes in, you save a life. Teaching- 
hospitals still have to be concerned 
with technical excellence and care for 
the most complex and problematic of 
cases, he says, but the real issue now in 
health care is health of the population. 

"This means that instead of being 
intensely concerned with whatever 
patient happens to cross our moat and 
get into this medieval enclave, where 
they get the very best, we have to be 
concerned with the countryside," says 
Rabkin. "That means not that we want 
all of the countryside to come here, 
but rather another revolutionary con- 
cept for teaching hospitals: most care, 
most prevention, and most promotion 
of health belong in the community, 
where people are, and not at the teach- 
ing hospital." 

One might ask why the BI and 
Deaconess chose to merge legally and 
not just affiliate. "I think if you're 
really going to make it work, the closer 
you are, the better it will work," says J. 
Richard Gaintner, MD, former CEO of 
Deaconess and Pathway Network, 
then president of CareGroup. 
"Legally, financially, programmati- 
cally, and managerially it's better. This 
is one of the things we and others have 
learned from experiences across the 
country." A merger also made sense to 
them because the BI and Deaconess are 
right across the street from each other. 
"The more we can consolidate as one 
total organization, with single finan- 
cials and incentives aligned, (and the 
only way to do that is to be completely 
part of one another), the more success- 
ful you will be in controlling costs and 
gaining market share." 

Gaintner believes the new game is 
not just cutting costs, though you have 
to be efficient. "I really think the game 
is more on the revenue side by grow- 



Spring 1997 



Melted identities: tlie 
Betli Israel Deaconess 
Medical Center. 




ing your market share, which you can't 
do in a managed care environment as a 
single institution. But you gain market 
share by driving your prices as low as 
you possibly can. It's a price game." 

Even though Gaintner was already 
leading a network, he knew he had to 
forge other arrangements. "Someone 
said that bigger is better. Well I don't 
know if it's better, but if you're not 
bigger, you're not going to be around 
to find out. It's a very tough environ- 



ment. Boston has sustained lots of aca- 
demic institutions for a long time, but 
there's only so many academic pro- 
grams you can support." 

When he came to Boston from 
Albany Medical Center in the summer 
of 1989 to head the Deaconess, he 
found an excellent hospital, but one 
that was very focused on adult medical 
and surgical care for people with dia- 
betes, heart disease, cancer and AIDS. 
They didn't do obstetrics, didn't do 



pediatrics, did very little gynecology 
and had a level-one emergency service, 
so they couldn't take care of really 
serious problems. "We did a lot of 
soul searching and realized that the 
way the world was going, we were not 
going to be able to survive on our 
own." Gaintner was already open to 
forging relations in the Longwood 
medical area with the other hospitals 
who did what the Deaconess didn't do. 
When the dean convened the 



Harvard Medical Alumni Bulletin 








I 



group of teaching hospitals in 1993, "I 
was a great advocate of trying to get all 
of the Harvard Longwood institutions 
together," says Gaintner. "That was 
my fantasy. I have great respect for 
MGH, but they're across town and a 
different venue. Under that scenario 
the Deaconess would have fared very 
well." Right around this same time, 
Nashoba Hospital in Ayer came to 
him, asking to be under the Deaconess 
umbrella, and that became their first 



foray into acquiring or hooking up 
with other hospitals. 

Six months later, when MGH and 
BWH decided to splinter off for discus- 
sions on their own, the Bl, Deaconess 
and Children's continued to talk, but 
neither the BI nor Children's felt the 
time was right. Other community hos- 
pitals approached the Deaconess and 
by the summer of 1 994, they had four 
hospitals under their new parent cor- 
poration, Pathway Health Network. 
Still looking for a strong teaching hos- 
pital to round out Pathway's services, 
Gaintner began discussions with New 
England Medical Center, but negotia- 
tions fell apart seven months later. 
Soon after, Rabkin called him and sug- 
gested they should talk again. "I said, 
hallelujah, I've been waiting for this!" 
says Gaintner. Mt. Auburn was also 
conferring with the BI, and by June 
1996 the three were talking together. 

There has, of course, been staff 
nervousness as a result of this merger. 
Communication is key, says Rabkin. A 
rumor swept through the Deaconess, 
for example, that because they were 
joining with the Beth Israel, they were 
not going to be able to celebrate 
Christmas anymore. "This is of course 
ridiculous," says Rabkin, "but when 
change is cataclysmic like this, people 
are whistling in the dark and rumors 
abound. The first two letters of 
merger are me — what is going to hap- 
pen to ?ne?" 

They have tried to appreciate that 
social change in an institution takes 
place over a period of years. It may 
take four to five years to "reweave the 
fabric of the two institutions into one." 
And it means that "you have to com- 
municate constantly and honestly with 
people, listen to what they're saying, 
and acknowledge them as part of the 
process," says Rabkin. 

The Beth Israel Deaconess is plan- 
ning a physical rearrangement: one 
board of trustees, one management, 
one department of medicine. Although 
the two hospitals are now connected 
by the "world's longest open-air corri- 
dor," they want to work out something 



better so that residents on one campus 
can easily get to the other to see a 
patient in the middle of the night. 
(The BI is now the "east campus" and 
the Deaconess is the "west campus.") 
They are in the midst of proximity 
studies: if the emergency unit is on the 
west campus, what clinical services 
should be proximate to it and what 
could be at the other campus? You 
need cardiology, trauma care, the heli- 
copter pad nearby, for example, but 
not obstetrics. What are the costs — 
functionally and financially — if the 
location of a unit is on one campus 
versus the other? "This is the kind of 
thinking that goes into proximity stud- 
ies," says Rabkin, "and we're doing it 
department by department." 

CareGroup's network of physi- 
cians, physician groups, hospitals and 
nonacute facilities is not fully formed, 
and they are "trying to work out ways 
to grow the system in strategic ways." 
They want the system to be fully inte- 
grated so patients can move seamlessly 
from one office or institution to 
another, based on what physicians 
determine is best for them in terms of 
level of care and cost issues, and get 
patients back close to home as soon as 
appropriate. 

What it will come down to is "a 
balancing act," says Gaintner, "I call it 
the mission/money dilemma. How do 
you do what you need and want to do 
and still survive from a financial stand- 
point?" With a small percentage of the 
population generating most of the 
cost, the only way it will work is if you 
have a broad base of insurance, so that 
people who don't have problems 
essentially cover those who do. But the 
problem is that "the only way to make 
money in managed care is to enroll as 
many people as possible who don't 
have problems and exclude those who 
do," says Gaintner. "They deny this 
and around here it is not a big issue. 
But there's this old story that in 
California an HMO put their enroll- 
ment center on the third floor without 
an elevator: if you were healthy 
enough to walk up there, they wanted 



Spring 1997 



23 



V" 



( 




Children's Hospital stays 
independent. 



you; if you couldn't, they didn't." 

Gaintner has just been lured away 
to the University of Florida to be CEO 
of Shands Health System, an orga- 
nized delivery system involving the 
University of Florida in Gainesville. 
But he emphasizes that he really 
believes in the CareGroup construct. 
"When I came to Boston in 1989, the 
Deaconess had 489 beds and the BI had 
504. We're planning to run a 650-bed 
hospital and my guess it could go 
down to 500 beds. That's half what we 
both had. Like it or not, that's part of 
the game." 



Children's Strategy 

Children's Hospital has been wooed 
by many of the health care systems, 
but has remained steadfastly deter- 
mined not to tie itself exclusively to 
one system. "We honestly believe that 
when you have a unique resource like 
Boston Children's it should be made 
accessible to everybody," asserts David 
S. Weiner, CEO of Children's. "Ideally 
what Fd like to see us do is develop an 
independent pediatric delivery system, 
with Children's at the core, that 
responds to the needs of multiple sys- 
tems." 

This strategy is consistent with the 
hospital's mission to provide care to all 
children who need top-quality care 



and their families, says Weiner, and 
"we beheve it is also politically sensible 
to have no exclusives, because to the 
extent you make it to the competitive 
advantage of one system, you're cut- 
ting yourself off from another." 

This attempt at independence — or 
at being Switzerland, as one observer 
affectionately termed it — "doesn't 
mean we don't need to develop affilia- 
tions with other adult systems," 
Weiner emphasizes. 

Their overall institutional strategy 
is to create a "high quality cost-effec- 
tive system of pediatric care through- 
out the Boston area through setting up 
our own sponsored satellites, and by 
connecting with pediatricians in the 



24 



Harvard Medical Alumni Bulletin 





communities and with community 
hospitals." They also plan to expand 
their base of national and international 
referrals. 

Children's already has three outpa- 
tient satellite clinics — in Chelsea, 
Lexington (with the Beth Israel 
Deaconess) and Peabody — and is 
building a network of "relationships" 
with pediatric primary care physicians. 
They plan to forge model affiliations 
with community hospitals, as they 
recently did with Winchester Hospital. 
Children's pediatricians will provide 
inpatient and urgent pediatric care 
coverage for Winchester 24 hours a 
day, and will continue to staff the 
Special Care Nursery as they have 



since 1988. This brings specialized 
pediatric services to the community 
and "affirms our commitment to see- 
ing that any child who needs care is 
locally based as much as possible." It 
also serves to redeploy staff. 

Children's also operates a 71 -bed 
pediatric long-term care facility in 
Groton and last year purchased Night 
Train Pediatrics, an after-hours triage 
service for parents of sick children. 
Piece by piece they are adding to their 
system. 

Times have changed, and the future 
objective is not necessarily to fill beds 
here in Boston anymore, points out 
Weiner, though "when a patient does 
need complicated secondary or tertiary 
care, we'd like to think that there are 
enough screening and protocols at the 
local level to determine when a child 
should be referred here." 

The payback is the increased lever- 
age a system such as this may have in 
negotiating and contracting with 
insurers. As the Boston Business Jownial 
pointed out last year when Children's 
announced its plans: "The contracting 
advantages alone could be enormous, 
if only because many HMOs may be 
loathe to exclude such a popular hospi- 
tal from most people's insurance cov- 
erage." In fact. Children's has 
negotiated contracts with all of the 
region's major payors. 

Children's Hospital is 127 years 
old, the second oldest children's hospi- 
tal in the country (after Phila- 
delphia's), and one of only about 25 to 
30 academic pediatric centers. It trains 
more pediatric specialists than any 
other center in the world; last year its 
pediatric training program, newly con- 
solidated with Boston City Hospital's, 
was the most sought after in the coun- 
try. Boston's Children's is the top 
pediatric facility in receipt of federal 
research grant monies. 

But that very success puts an extra 
financial pinch on Children's. "We're 
nervous that just about every payor 
today is looking to avoid costs unre- 
lated to their objectives and that means 
costs of graduate medical education, 



research and community service, 
which are three key pieces of our mis- 
sion," says Weiner. "That's why we're 
aggressively advocating at the state and 
federal level for an all-payor pool for 
graduate medical education." 
Children's is also hurt because "the 
bulk of payment to hospitals comes 
from Medicare and independent chil- 
dren's hospitals are Medicaid- 
focused." 

Weiner acknowledges that there 
are economic risks to the strategy they 
have devised. Just as there is excess 
capacity among Boston's teaching hos- 
pitals, there are excess pediatric ser- 
vices. Not all can or should survive. 
And though Children's is fully pre- 
pared to rationalize services, Weiner 
says, they fully expect to be one of the 



survivors. 



Collaborating on Cancer 

David Nathan '55 says he took on the 
presidency of the Dana-Farber Cancer 
Institute a year and a half ago knowing 
that he'd be making changes in the 
way adult clinical oncology was prac- 
ticed there. The institution was ripe 
for change, in part because of the pub- 
licized chemotherapy overdoses. From 
his pediatric experience at DFCI and at 
Children's — he had been chief of pedi- 
atric hematology/oncology for both 
before becoming Children's physician- 
in-chief — he already had a model. 

"We have the Jimmy Fund Clinic 
at DFCI which is just a nonpareil, mag- 
nificent program for children with 
cancer and there's no clinic like it any- 
where in New England," he explains. 
"But when children get sick, either 
from their treatment or the disease, 
there's no place like Children's 
Hospital for inpatient care, so all our 
patients go there. I wanted to repro- 
duce that for adults." 

Hospitals have the "bells and whis- 
tles" necessary to take care of acutely 
ill patients who require hospitalization. 
"But cancer centers, I think, are much 
better in ambulatory care and about 85 
percent of care of a cancer patient is 
ambulatory." 



Spring 1997 



25 



Because there was alread)' a bridge 
to the Brigham, says Nathan, that was 
the logical place to go. The fact that 
the Brigham and the AIGH had formed 
Partners opened an opportunity to 
integrate adult oncology care across an 
even larger system. "Among the three 
institutions there are about 200 oncol- 
ogy beds and almost 200,000 visits," 
says Nathan. "We asked ourselves how 
we could put this all together into a 
fascinating and new approach to can- 
cer care that would allow us to become 
one of the largest providers in the 
countr}^ and have seamless quality and 
excellence, whether you got into the 
system from the MGH, Brigham or the 
Farber." 

Their collaborative program, 
Dana-Farber/Partners CancerCare, 
was announced in January 1996. Not a 
merger, but rather a "joint venture," it 
involves adult care only. DFCI has 
moved its licensed beds to the 
Brigham and the Brigham's ambula- 
tory oncology program will be moved 
to the Dana-Farber; the MGH will 
maintain both its outpatient and inpa- 
tient programs. Oncology patients will 
have access to care at any one of the 
three institutions, researchers will have 
a larger pool of patients with rare can- 
cers, specialists will consult through- 
out the system, and clinical guidelines 
will ensure care is consistent and cur- 
rent. 

Thus far all cancer care between 
the Brigham and DFCI has been inte- 
grated. "It is hard to imagine how 
complicated this was," says Nathan. "It 
required moving patient beds, closing 
clinical laboratories here and opening 
there, integrating information systems. 
There was one issue after another to 
resolve." 

The next step is to integrate cancer 
care between DFCl/Brigham and the 
MGH, an even larger undertaking 
because the volume of adult cancer 
care at MGH is equal to the combined 
volume of DFCI and the Brigham. 
"Plus they have their own way of 
doing things. Their system of care is 
more private-practice oriented and 



ours is more of a clinic-based team 
approach. But if we're going to adver- 
tise that we have a common system, 
we're going to have to compromise." 

Nathan says that this is not an 
exclusive agreement with Partners in 
that they will continue established 
arrangements with the BI — for exam- 
ple, an advanced breast cancer treat- 
ment program and head and neck 
program. "But obviously the Beth 
Israel Deaconess Medical Center will 
have its own cancer program so the 
vast predominance of what we do will 
be with Children's and Partners." 
They will still care for other patients, 
in part because the DFCI is a federally 
designated regional cancer center, and 
is federally mandated to care for any- 
one who needs help. 

DFCI is building what he terms a 
patient- and family-oriented system 
that will offer unsurpassed cancer care. 
He says the DFCI is also far better off 
financially by getting rid of its inpa- 
tient beds: "You can't break even with 
30 or 40 beds." Nathan says the DFCI 
receives enormous public support, but 
that's because of "public confidence 
that we'll find a new approach to can- 
cer, not that we'll fund a deficit on a 
small number of beds. Unless of 
course the small number of beds is 
better for patients, which it's not." 

One of Nathan's top concerns is 
"the constant slashing of reimburse- 
ment that has cut down the ability of 
hospitals to support research." 
Nathan, who heads an NIH committee 
investigating the effects of shrinking 
revenue to support promising clinical 
scientists, says that doctors are feeling 
beleagTaered and, from anecdotal evi- 
dence, are afraid of getting into sci- 
ence careers. 

"Basically we've always relied on 
the teaching hospitals to have enough 
money in the till to support young 
physicians," says Nathan. "We can't 
do that anymore. There's this latest 
cheery idea that we're going to cut 
Medicare more. Well, here we already 
lose $2 million on Medicare patients; 
that's just one teaching hospital losing 




$2 million. We do more for patients 
than insurance will reimburse us for. 
Where are we supposed to get the 
money?" 

The crisis is serious, he believes. 
Chemistry and physics funding is 
declining rapidly, and these are two 
disciplines upon which biomedical 
research depends. "We may not notice 
it right away but in a decade there will 
be a lot of information we won't have. 
As a country we are dropping into sec- 
ond tier with respect to the fraction of 
GNP that goes into research and devel- 
opment. It won't take long before 
we're feeling second tier." 

Competitive Forces 

Though clinically these six Harvard 
teaching hospitals may not be "all for 
one and one for all," they all say they 
are expressly concerned with their 
research and teaching mission. 
Inevitably there has been some erosion 
of collegiality because to compete 
means to accentuate the differences. 
But as David Weiner of Children's 
says, "I fail to see why competition 
needs to preempt rational collabora- 
tion and integration of effort among 
Harvard and its teaching hospitals." 
In discussing competition, several 



16 



Harvard Medical Alumni Bulletin 



CEOs pointed out that competition can 
improve things for everybody, includ- 
ing patients. Sam Thier of Partners 
quotes Harold Shapiro, the president 
of Princeton, who said that at a certain 
level competition can be seen as coop- 
eration with ground rules. "We want 
to make sure our competitors are the 
strongest we can have," says Thier. 

With two strong general hospital 
systems, there is naturally competition, 
but as Mitch Rabkin of CareGroup 
says, it is not competition to destroy 
the other so much as "I want to be the 
best so I'm going to do the best we 
can." He believes there are still many 
coUegial things happening and that the 
hospitals are finding other ways of 
sharing. 

But how have the realignments 
affected Harvard Medical School? 
Because patient care is interwoven so 
closely with medical research and edu- 
cation, comments Dean Tosteson, the 
accommodations to change that the 
Harvard-affiliated hospitals have made 
"have had a great impact" on Harvard 
medical faculty who work at these 
institutions. "To the extent that the 



new arrangements between the hospi- 
tals are a sincere effort to improve the 
quality, cost-effectiveness and accessi- 
bility of health care and sustain and 
strengthen the academic mission of 
education and research, I applaud," 
says Tosteson, who points out that it 
was concern about the need for such 
restructuring that prompted him to 
convene the leaders of the five largest 
teaching hospitals four years ago. 

"However, the current situation 
falls seriously short of my hopes. Many 
members of our clinical faculty are 
caught in a painful bind between their 
obligation to participate in the increas- 
ingly ruthless competition with their 
colleagues at other institutions for 
clinical business and their desire to 
collaborate in research and education. 
Competition between Harvard-affili- 
ated organizations saps energy and 
focus on competing with other private 
and public providers of health care 
outside the system. It also distracts 
attention from the important problem 
of access to health care for the poor 
and underinsured." 

Tosteson's hope now, he says, is 



that "additional mergers or partner- 
ships between Harvard-affiliated 
healthcare institutions and Harvard 
faculty physician organizations will 
move in the direction of a more coher- 
ent, cooperative, collegial and, there- 
fore, productive Harvard medical 
community." 

"A lot of the tension that was in the 
system has already dissipated," points 
out Richard Kitz, HMS faculty dean for 
clinical affairs and for 2 5 years chair- 
man of anesthesiology at MGH. "It's 
easier to get people in the same room 
because they're feeling more comfort- 
able and less threatened. The firma- 
ment of Harvard medicine is clearer 
now." But the concern remains that 
with "all this attention to the business 
of medicine that research and educa- 
tion are not forgotten." 

Kitz already had his eyes on retire- 
ment when he was invited by the dean 
in October 1994 to, as he says, "work 
the issues between the school and its 
affiliates." "There are 18 affiliates!" 
Kitz said he responded. "Is this one of 
those mission impossible assignments 
that will self-destruct if I don't 



The Other 
Twelve 

The other Harvard-affiliated 
hospitals have their own strate- 
gies for economic survival. 

Massachusetts Eye and Ear 
Infirmary is still independent 
and part of its strategy is to 
stay independent. Though the 
hospital has long-standing pro- 
grams and relationships with 
Brigham and Women's and 
Massachusetts General hospi- 
tals, MEEI would like to con- 
tinue to see patients from all 
plans and systems of care. 



Joslin Diabetes Center, for the 
past ten years, has followed a 
growth strategy of establishing 
affiliates (essentially fran- 
chises] around the country. 
These affiliates (now number- 
ing 14) sign an agreement and 
pay an annual fee, and in 
exchange can use the Joslin 
name, receive procedures and 
protocols for the Joslin-style 
diabetes practice, and have 
site visits and network confer- 
ences. Joslin also has five local 
diabetes center satellites. As 
for arrangements with other 
hospital networks, communica- 
tions director Julie Rafferty 
says: "At this point Joslin has 
affiliations with hospitals in the 
Boston area and is talking 
about how these affiliations 
can be broadened." 



The Cambridge Hospital 
merged last July 1996 with 
Somerville Hospital, creating 
the Cambridge Public Health 
Commission. This is the gov- 
erning board for the two hospi- 
tals, the health centers that 
were previously connected with 
the two hospitals, the 
Cambridge Department of 
Public Health, the Neville 
Manor Nursing Home, and the 
Cambridge Hospital 
Professional Services 
Corporation (their practice 
plan). Cambridge Hospital is 
also in the process of talking 
with both Partners and 
CareGroup, "hoping to estab- 
lish a tripartid arrangement so 
we can affiliate with both," 
according to Luke Wennik, 
assistant manager of public 



relations. "We consider this 
absolutely essential for sur- 
vival." 

Massachusetts Mental Health 
Center is still a state-run facil- 
ity, which continues collabora- 
tive relationships with HMS 
and other mental health facili- 
ties in the Boston area. MMHC 
has not merged with anyone, 
says Ming Tsuang, MD, PhD — 
superintendent of MMHC and 
HMS Stanley Cobb Professor of 
Psychiatry — who adds "Mass. 
Mental's mission is unwaver- 
ing." 

Harvard Medical School has a 
total of 18 affiliates. The oth- 
ers are: the Spaulding 
Rehabilitation Hospital and 
McLean Hospital, both of which 



28 



Harvard Medical Alumni Bulletin 



accept?" "No," the dean said, "this one 
won't go away." 

In essence, for the past couple of 
years Kitz has been working to help 
ensure that the divisiveness among the 
teaching hospitals does not impede the 
academic discourse that transcends the 
faculty's institutions. In Kitz's estima- 
tion the faculty are HMS. "I think the 
purposes of a university are, as John 
Henry Cardinal Newman at Oxford 
said so marvelously, 'to store knowl- 
edge, to disseminate knowledge and 
discover new knowledge'. Now who is 
responsible for this? It's the faculty 
who do the research and teaching, not 
those of us in administration." 

As Kitz further points out, there are 
14,000 appointees (including residents 
and fellows) and more than 90 percent 
of them are in the affiliated hospitals. 
No one could be more committed to 
the medical school than the leaders of 
that faculty, he says, the ones with 
appointing privileges and who allocate 
the resources to other faculty to do the 
research and teaching. "They are the 
glue that holds Harvard faculty 
together," says Kitz. Using himself as 

are affiliated witii MGH and 
Partners; tlie Judge Baker 
Guidance Center, part of 
Cliildren's; tlie Brocltton and 
West Roxbury V.A. Medical 
Centers; the Center for Blood 
Research; and the Schepens 
Eye Research Institute. 

EB 



an example, he adds that as chief of 
anesthesiolgy, "I was as truly commit- 
ted to the affairs of the medical school 
as I was to MGH; I'd bleed crimson as 
well as blue." 

He meets regularly with faculty 
leaders of the 16 clinical departments, 
under the aegis of Harvard, where they 
discuss promotions, appointments, res- 
idency programs, research that cross 
cuts institutions, such as center grants 
and program projects, and communi- 
cations from the dean. His office over- 
sees compliance with the "Guidelines 
for Faculty Compensation" and 
"Guidelines for Practice Plans." 

And recently, he and colleagues at 
Countway Library and the HMS 
Department of Information 
Technology have created a virtual 
Harvard Medical Center using World 
Wide Web technology. Called the 
Harvard Medical Center Network, it 
provides computer links to all of the 
affiliates and clinical departments, pre- 
clinical departments and student soci- 
eties. Its purpose is to support the 
inter-institutional mission of research 
and teaching, to "break down some of 
the impediments there are to moving 
around the system and allow our fac- 
ulty, students and residents to commu- 
nicate throughout," says Kitz. 

But getting back to the crux of the 
matter for HMS: how can the school be 
certain the teaching and research mis- 
sion will be preserved and enhanced 
when the faculty are mostly "out 
there" and "out there" has changed so 
much? First CareGroup, then 
Partners, made major commitments by 
appointing senior physicians as vice 
presidents for academic programs, 
Michael Rosenblatt '73 for CareGroup 
and Eugene Braunwald for Partners. 
Both are faculty deans for academic 
programs at the medical school, and 
thus hold high-level appointments at 
their hospital systems and the medical 
school. Starting last fall, they began to 
meet monthly together as the dean's 
Council of Academic Deans with col- 
leagues holding similar appointments: 
Thomas Inui, MD at Harvard Pilgrim 



Health Care, Philip Pizzo, MD at 
Children's, and David Nathan '55 at 
the Dana-Farber. 

As Dean Tosteson steps down at 
the end of June, one of the challenges 
for his successor, Joseph Martin, MD, 
PhD, will be to catalyze further unifica- 
tion on the research and teaching mis- 
sions. Martin, who is currently 
chancellor of University of 
California/San Francisco, has said that 
he looks forward to taking on the chal- 
lenges of returning to Harvard, where 
he was chairman of neurology at MGH 
from 1978 to 1989. As he has also said, 
this is an unstable time for academic 
medicine and Harvard is no exception. 

Ellen Barlow is editor of the Harvard 
Medical Alumni Bulletin. 



Spring 1997 



29 




100% 




Changes and projected changes 
in the relative sizes of five 
racial-ethnic groups in the U.S. 
population 1980-2050 



□ White 
D Asian 
n Hispanic 

■ Native American 

■ Blacit 







- 


-1 




■1 








40% 


< 






20% 


. ■ 


I 1 


nil 


1980 1990 2000 



'T 



> 




30 



Harvard Medical Alumni Bulletin 




2010 



2020 



2030 



2040 



2050 



Complexion 
of Change 



by Jordan J. Cohen 



Finishing the bridge 
to diversity 



We in academic medicine are chal- 
lenged as never before to build that 
metaphorical bridge to the future, 
which is so much the rage these days. 
We are working especially hard to find 
ways to sustain academic medicine's 
core missions as we bridge the turbu- 
lent sea of changes swirling around us. 

Within our world, there is a long- 
standing challenge that needs our 
commitment: finishing the bridge to 
diversity. This bridge-building chal- 
lenge differs a lot, I think, from others 
that are commanding so much of our 
attention. For one thing, although the 
tools we need for this work stem, as 
always, from carefully honed analyses 
of the data, those tools must be sharp- 
ened for this particular task by some- 
thing in addition to data — by deeply 
felt passion. 

To establish the context for my 
remarks, let me review some familiar 
facts. The population of the United 



Spring 1997 



31 



States continues to grow and will do so 
well into the next century. The truly 
dramatic change to come, however, is 
not die size of our population but its 
composition. Our population is grow- 
ing older, as everyone knows, and it 
also is growing racially and ethnically 
more diverse. Minority populations 
are increasing much more rapidly in 
this country than is the majority white 
population. By the middle of the next 
century, the majority of our citizens 
will be members of minority groups. 

IV/yat do these striking demogi^aphic 
trends describing the future complexion of 
America have to do with our responsibili- 
ties as stewards of medicine''s future? 
Academic medicine is, after all, about 
improving the health of future genera- 
tions by educating the physicians who 
will care for tomorrow's children and 
by discovering better ways to keep 
tomorrow's children healthy. Given 
that our primary obligation to society 
is to furnish it with a physician work- 
force appropriate to its needs, our 
mandate is to select and prepare stu- 
dents for the profession who, in the 



aggregate, bear a reasonable resem- 
blance to the racial, ethnic and gender 
profiles of the people they will serve. 
In other words, a medical profession 
that looks like America. 

Why should anyone care if the medical 
profession reflects society's racial and ethnic 
makeup as long as we have plenty of well- 
trained practitioners of whatever back- 
givund? The reasons are many, but five 
stand out in my mind: 

First is the simple matter of justice 
and equity. The medical profession, 
and the health professions in general, 
occupy a lofty status in American soci- 
ety, and offer those who pursue them 
many of the most challenging and 
rewarding career opportunities avail- 
able anywhere. For us to seek justice 
within our own profession is, I believe, 
only to be faithful to our cardinal com- 
mitment to respect everyone's individ- 
uality equally. 

The second reason is a matter of 
improved access to health care for the 
underserved. Abundant data now exist 
to document unequivocally that black, 
Hispanic, and Native American physi- 



cians are much more likely than 
whites and Asians to practice in 
underserved communities. Not that 
minority physicians are, or should 
be, under any obligation to do so; 
not that minority physicians are not, 
and should not be, free to settle and 
practice wherever and however they 
chose; and not that other physicians 
do not contribute importantly to 
improving access among the under- 
served. The simple fact is that 
minority physicians do so with 
greater predictability. Getting the 
job done means producing more 
minority physicians to lead the way. 

The third reason for increasing 
diversity among our students — and 
faculty, I might add — has to do with 
learning how to deliver culturally 
competent care. Given the expand- 
ing diversity throughout our society, 
all physicians of the future will need 
this essential skill, and must be given 
a strong foundation in what it means 
to deliver culturally competent care. 
If they are truly to care for their 
diverse patients, physicians of any 
background must have a firm grasp 



Enriched by 
Diversity 

The most striking cliange over 
the more than 25 years that I 
have been involved with the 
HMS Admissions Committee 
has been the increasing diver- 
sity of our student body in 
terms of gender, ethnicity and 
bacitground. Our process is 
truly gender blind and half of 
our students are now women. 
We also have a responsibility 
to train physicians for our 
increasingly pluralistic society, 
and that means including stu- 
dents of all races and ethnic 
backgrounds. We are all 
enriched by the diversity of our 
students. 



The phrase "affirmative 
action" has been used to 
describe some of these efforts 
and with it come misconcep- 
tions: that there are quotas or 
that poorly qualified students 
are being offered places. 
Nothing could be further from 
the truth. 

All students we accept demon- 
strate outstanding scholarship 
and intellectual curiosity. Most 
are science majors, but many 
are not. We value breadth of 
education as well as the ability 
to pursue something in depth, 
whether it be scientific 
research or an honors thesis in 
the humanities. 

But we look for more. One of 
our committee members said, 
"Being smart is not enough. 



You have to be nice." Personal 
qualities are just as important 
as academic accomplishment. 
We look for qualities of leader- 
ship, integrity and a commit- 
ment to serve. Our students 
bring with them an impressive 
list of talents, out-of-classroom 
activities, life experiences and 
community service. Many have 
had to overcome personal 
hardships and have emerged 
stronger for these experiences. 
We are seeing an increase in 
the number of somewhat older, 
nontraditional applicants who 
bring with them a set of experi- 
ences and a level of maturity 
that adds leavening to a class. 

Our programs put a premium 
on good communication skills 
and the ability to work 
together. Good communication 



skills also mean good listening 
skills as well as the ability to 
communicate easily with peo- 
ple from different nationalities 
and ethnic groups. 

We look for these qualities in 
the applications submitted, in 
letters of recommendation and 
in the personal statements 
written by the applicants. 
These are read by members of 
the Admissions Committee and 
those with the most compelling 
credentials are invited for 
interviews (about 20 to 25 per- 
cent of close to 4,000 appli- 
cants last year). 

Although hard to validate, the 
interview plays an important 
role, it gives us a sense of 
whether someone is not just 
smart, but nice. We learn 



32 



Harvard Medical Alumni Bulletin 



on how various belief systems, cultural 
biases, family structures, historical 
realities, and a host of other culturally 
determined factors influence the way 
people experience illness and how they 
respond to advice and treatment. Such 
differences translate into real differ- 
ences in the outcomes of care. 

A fourth reason for addressing 
diversity has to do with our research 
agenda. Our society as a whole is 
plagued by unsolved health problems, 
many of which revolve disproportion- 
ately around our minority populations. 
Our country's research agenda is set in 
large measure by those who have cho- 
sen careers in investigation. Individual 
investigators, in turn, tend to do 
research on problems that they "see" 
and are of interest to them. And what 
people see depends to a great extent 
on their particular cultural and ethnic 
filters. 

My final reason for achieving diver- 
sity in the medical profession relates to 
management of the health care system. 
Physicians must continue to lead in the 
management of the health care enter- 
prise, especially now that that enter- 



prise is becoming increasingly corpo- 
ratized. But assuming management 
responsibility for a system destined to 
serve the health care needs of an 
increasingly diverse people is a job that 
can only be done well by equally 
diverse management teams. We must 
draw the future physician leadership 
for our health care systems — as we 
must for all other professional and 
nonprofessional sectors of the 
American economy — from a richly 
diverse pool of talent, adequately 
reflecting our country's gender, racial 
and ethnic melange. 

Let's take an historical look to see 
how are we doing in our quest for 
diversity. Until the mid 1960s the 
racial and gender composition of med- 
ical school classes was composed pri- 
marily of white men. Despite a 
progressively expanding, double-digit 
presence in our population, groups 
that we now designate as under-repre- 
sented minorities made up only about 
2 percent of medical school matricu- 
lants, and three-quarters of those 
attended either Howard or Meharry. 

The typical medical school of that 



something about communica- 
tion sitills and personality. 
Applicants have an opportunity 
to tell us more about them- 
selves and we have an opportu- 
nity to explore accomplish- 
ments and values. Applicants 
also have an opportunity to 
learn more about us. Medical 
schools interview. Law schools 
do not. Perhaps there is a mes- 
sage there. 

So that's our student body and 
the qualities we look for. The 
selection process is a collabo- 
rative effort of more than 50 
faculty and 20 students in any 
given year. About 20 alumni in 
Atlanta, Chicago and California 
participate in our regional 
interviewing trips to these 
areas. It is not exactly a sci- 
ence, but it is a careful and 



fair process. For the members 
of the Admissions Committee, 
it is a time consuming and 
intensely rewarding experi- 
ence. The end result is a stu- 
dent body of which we can all 
be proud. 

Gerald S. Foster '51 is HMS 
faculty associate dean for 
admissions. 



era admitted one minority student 
every other year. I graduated from 
Harvard Medical School in i960, one 
of the off years. In my class of 140, 
there were 134 white men and 6 white 
women. And that was a banner year for 
women. In my 1965 residency class, 
there were no women, no blacks, no 
Hispanics, no Native Americans, nor 
any Asian Americans. Racial segrega- 
tion was as fully evident in medicine as 
it was in virtually every sector of 
American society, just as it had been 
for many preceding decades. 

But things began to change in the 
late 1960s, and academic medicine was 
among the first to get the wake-up 
call. The result was a dramatic rise in 
the admission of minorities to medical 
schools. Was this because Scholastic 
Aptitude Test scores, grade-point 
averages, and Medical College 
Admission Test scores of minority stu- 
dents suddenly began to skyrocket? Of 
course not. What changed was simply 
that academic medicine began to take 
affirmative actions to increase the 
racial, ethnic and gender diversity of 
medical school classes. 

Enrollment of under-represented 
minorities in U.S. medical schools rose 
rapidly to about 8 percent of all 
matriculants by the early 1970s. 
However, progress on diversity stalled 
in the mid seventies, with admissions 
remaining virtually flat for the next 1 5 
years or so. To make matters worse, 
the fraction of individuals from the 
same groups in the U.S. population 
that were under-represented in medi- 
cine continued to grow during this 
period, increasing from 16 percent in 
1975 to 19 percent in 1990. Our 
bridge to diversity, in other words, was 
less than halfway across the chasm and 
the gap was widening before our eyes. 
Clearly it was time to call in the engi- 
neers to reevaluate our bridge-build- 
ing strategy. We did so, and the result 
was the AAMC's Project 3000 by 2000. 

The architects of this project rec- 
ognized that the root cause of minority 
under-representation in medical 
schools in this era is the accumulated 



Spring 1997 



33 



academic disadvantages of too many 
minorit}' young people, simply because 
they lack access to high-quality, prec- 
ollege and college educations. Thus, 
the project aims, over the long term, 
to effect small-scale educational 
reform. Science education partnerships 
have been created to identify promis- 
ing" students early in the educational 
pipeUne, enrich the science and related 
offerings available to students from 
poorly equipped schools, establish 
mentoring relationships to keep the 
flames of inquiry and aspiration burn- 
ing intensely, and to provide adequate 
counseling to ensure that all the mile- 
stones on the long road to medical 
school are understood and met. 

After the launch of Project 3000 by 
2000 we saw a second dramatic upturn 
in the number of under-represented 
minorities admitted to medical school. 
But over the last two years, progress 
has lapsed once again. One reason for 
the project's early success was the new 



TbepClass-^f4 



attention it focused on the lack of ade- 
quate racial and ethnic diversity 
among medical students. We saw a 
significant increase in the fraction of 
under-represented minority applicants 
who gained acceptance at virtually 
every school. The measurable progress 
made during this initial phase vali- 
dated, once again, the power of affir- 
mative action as a short-term remedy. 
Now it's precisely such short-term 
remedies that are in jeopardy. What 
may be running out of steam is our 
commitment to affirmative action pro- 
grams, programs designed to reach out 
not only to those qualified young peo- 
ple from under-represented minority 
groups who are already in the appli- 
cant pool, but also to those who should 
be in the pool, and to those who, 
through short-term academic enrich- 
ment efforts, could qualify to enter the 
pool. The suspicion that weakened 
affirmative action efforts may be the 
culprit here has an obvious reason. 



given the way affirmative action is 
being attacked on so many fronts. 

Critics of affirmative action raise 
repeatedly the question whether the 
use of affirmative action as a tool, and 
the resulting increase in the number of 
minority medical students, leads to 
unqualified individuals becoming doc- 
tors. To raise such a question is to 
concede ignorance of the facts. No one 
would argue for admitting anyone to 
medical school who did not evidence 
the academic skills and personal quali- 
ties necessary for completing the MD 
degree. Such an admission policy 
would not only violate our oath to 
patients, it would be a disastrous dis- 
service to individual students. 

The vast majority of medical stu- 
dents from under-represented minor- 
ity groups, as is true of all students 
admitted to medical school, do suc- 
cessfully complete the rigorous 
requirements for graduation. Medical 
school admission committees cannot 




oos 



1960 1964 1968 1972 1976 1980 1984 1988 1992 1996 



34 



Harvard Medical Alumni Bulletin 



Admission of under 
represented minorities 
to medical school 



» ■^ 



be commended enough for the care 
they take in selecting our country's 
future physicians. That only a handful 
of students from all backgrounds, 
majority and minority alike, prove 
unable to withstand the rigors— or 
meet the financial costs — of a medical 
education and must abandon the quest 
along the line, is ample testimony to 
the skill and wisdom of our admission 
committees. 

Those who oppose affirmative 
action, and I know many of you do, 
argue either that it's no longer needed, 
or that it's ineffective, or that it's 
unfair. Looking at this contentious 
issue from the vantage point of the 
medical profession, I maintain that all 
three of those arguments are false. 

Is ajfliinative action in 7nedical school 
admission still needed? Absolutely. Until 
the academic credentials of all groups 
in the applicant pool are indistinguish- 
able, we simply cannot use the same 
criteria to evaluate all applicants. 
Given the disparity in available mea- 
sures of academic achievement among 
applicants grouped by race and ethnic- 
ity, there is simply no way we can 
select an adequately diverse class of 
medical students today without taking 
race and ethnicity explicitly or implic- 
itly into account. We must continue 
for as long as necessary to reach out to 
those whose race and ethnicity, not 
their economic status alone, have sub- 
jected them to inferior academic 
preparations, but who, by dint of char- 
acter, intelligence and drive are fully 
prepared to succeed as physicians and 
medical scientists. 

Is affii'viative action ineffective! 
Certainly not in medicine. Indeed, 
nowhere is the effectiveness of affirma- 
tive action more in evidence than in 
our profession. Effective not only in 
narrowing our diversity gap, but effec- 
tive in greatly expanding access to 
care. 



Is affinnative action unfair'? How can it 
be unfair to boost the chances of 
becoming a physician — to give special 
treatment to persons who have been 
subjected to unfair discrimination 
because of their heritage, and whose 
status in our democratic society 
remains tarnished through no fault of 
their own? What about fairness to 
other applicants who don't get the 
benefits of affirmative action? Most 
applicants to medical school come 
away empty-handed, and do so for a 
whole variety of reasons. To single out 
affirmative action for their disappoint- 
ment and plead unfair treatment just 
doesn't compute. 

If one of my kids or grandkids were 
rejected from medical school, I'd be 
damned disappointed. But if they tried 
to blame it on reverse discrimination, 
I'd say: get a life. Because I believe it's 
time already to share the wealth, to 
recognize that our profession needs — 
and our country needs — the best talent 
it can find from every group in our 
society. 

As much as we'd like to think oth- 
erwise, and as much as we long for the 
day when it's no longer true, race and 
ethnicity still matter in America. To 
ignore that reality in deciding who 
deserves to be admitted to medical 
school is to ignore our duty as stew- 
ards of our profession's future. 

We must continue to produce 
physicians and scientists from all seg- 
ments of America. We must remember 
how many young minority physicians, 
with their many talents and abundant 
energy, would have been lost to us if 
the enrollment practices from my era 
in medical school had not been 
reversed by affirmative action. But 
simply repeating the rhetoric of the 
1960s will not be enough. We must 
face up to the fact that our society is 
being hammered at present by a mean- 
spirited backlash. 

All of us must speak out. This is a 
moral issue, and it is a health issue. 
Hence, it is our issue. And the data are 
compelling. The consequence of aban- 
doning affirmative action programs 



prematurely will be a reduction in the 
availabihty, and a deterioration in the 
quality of, health care services for 
everyone. 

We must finish the bridge to diver- 
sity we began to build in the 1960s. 
We cannot allow thoughtless attacks 
on affirmative action to dismantle the 
fledgling structure we have yet to com- 
plete, a structure without which at 
least some of our minority colleagues 
would never have attained their 
dreams, never have healed a patient, 
never have discovered new knowledge, 
never have led an institution, never 
have inspired a student, and never have 
graced our profession. ^ 

Jordan J. Cohen '60 is president of the 
Association ofAinerican Medical Colleges. 
This is adapted fi-0171 his address at the 
annual meeting in San Francisco on 
November 8, 1996, and was published in 
its entirety in the February 1997 issue of 
Academic Medicine. 



Spring 1997 



35 




Harvard Medical Alumni Bulletin 



Taking It to 
the Streets 



by Janet Walzer 



Every street corner is different. 
Here at the corner of Columbia and 
Washington in Dorchester, Robert sits 
inside the Family Van as his 16-year- 
old wife, Lisa, has her blood pressure 
checked by nutritionist Ellyn Baltz. 
Robert's family history of high blood 
pressure and diabetes prompted his 
first visit to the Family Van just a week 
ago. Robert, who is 20 years old and 
works at a nearby restaurant, is study- 
ing for his high school equivalency, 
and notes that his career plans had to 
change "once there was a baby on the 
way." Robert and Lisa are now the 
parents of two-month-old Anna. 

After spending about 1 5 minutes on 
the van, Robert and Lisa leave — Lisa 
with a healthy blood pressure of 98/58 
and some nutritional information for 
Anna, and Robert with a stack of flyers 
about the Family Van written in 
English and Spanish. Robert has 
offered to distribute the flyers because 
"A lot of people need treatment and 
they don't know it's around." 

The Family Van has been "around" 
the most underserved areas of Boston 
for five years, first hitting the streets in 
January 1992. The idea originated 
three years earlier when Nancy Oriol 
'79, HMS assistant professor of anesthe- 
sia and director of obstetric anesthesia 
at what is now called Beth Israel 
Deaconess Medical Center, heard a 
National Public Radio piece on infant 
mortality. Oriol, who is founder and 
executive director of the Family Van, 
hoped that a mobile unit that tailored 



its services to meet the needs of a 
neighborhood could make a differ- 
ence. With the help of Cheryl Dorsey 
'92, Edward Lowenstein, HMS profes- 
sor of anesthesia, and Mitchell T. 
Rabkin '55, the current CEO of 
CareGroup, the Family Van became 
an idea realized. 

Although infant mortality was the 
impetus for the van, Oriol says the 
mission was always broad. "Infant 
mortality is only a symbol. We knew 
that the specific needs of our commu- 
nity would be redefined over time. It's 
logical to check blood pressures, do 
pregnancy testing, offer certification 
for Women Infants and Children 
Supplemental Food Program (wic), 
and help people understand the 
bureaucratic maze of health care. But 
in terms of health education and 
resources, we had no preconceived 
notion since every street corner is dif- 
ferent. People and times change and 
issues change." 

What has not changed in the past 
five years is that the Family Van serves 
as a bridge, referring clients to com- 
munity health centers, service agen- 
cies, and the multiple resources in 
their neighborhoods. There are over 
I GO local programs to which van staff 
can refer clients. The type of resources 
that might be needed, according to 
Oriol, "depends on who crosses the 
bridge. Our job is not to diagnose or 
treat, but to open a door." 

It is Oriol's dynamic spirit and 
down-to-earth approach, shared by 



that of the van staff, that explains 
much of its success. The van now cov- 
ers seven Boston neighborhoods, and 
the Family Van National Initiative has 
been established, with the first Family 
Van outside of Boston opening last 
November in Providence, Rhode 
Island. 

The van itself is a 35-foot long 
Winnebago with "We are Family" 
emblazoned in turquoise on its sides. 
Inside it is easy to forget it is a motor 
vehicle. The walls of the van are cov- 
ered with information on reproductive 
health care, healthy cooking, heating 
fuel assistance, food pantries and job 
assistance. Stations are set up for blood 
pressure checks and individual coun- 
seling, and there are bins full of sup- 
plies, clothes and toys. 

From 9:00 am to 12:00 pm, and 
again from 1:30 pm to 4:30 pm 
Monday through Thursday, the 
Family Van parks at the same location 
in seven different neighborhoods, 
regardless of weather and traffic. This 
consistency is not overlooked by 
clients, notes national director Tamara 
Callahan '95, who remembers one 
client saying, "The van comes to us. It 
kept coming and I finally came in." 

Mobility is one of the van's greatest 
strengths. It reaches clients who often 
are not seen in neighborhood health 
centers or clinics and attempts to 
address the specific needs of each com- 
munity. Boston director Claire Craig 
says the van's place in the community 
is unique for additional reasons. "We 



Spring 1997 



37 



offer i\ comfortable, no-questions- 
asked environment for clients to get 
support and information on health and 
life issues. Most staff live in the same 
neighborhoods our clients do. We 
pro^^de access to medical care and to 
people who care." 

This idea of accessibility is echoed 
b}' project coordinator Aleisa Gittens- 
Carle. "The climate is changing and 
people are trying to find out what's 
available to them. People often don't 
feel comfortable or confident asking 
about services. A person comes in for a 
blood pressure check, but there are 
other issues happening. You have to 
have a keen sense of hearing." 

This ability to hear the other issues 
is a trait that all van staff and volun- 
teers appear to share. Although many 
clients who come on the van this par- 
ticular morning request a blood pres- 
sure check, they have other things on 
their minds. Every person who steps 
out of the van is armed with informa- 
tion. One young woman new to the 
city leaves with a potential job inter- 



view and tips on losing weight; 
another client leaves with emergency 
formula and WIC certification for her 
three-month-old daughter; another 
now knows her blood glucose level; 
and several others have referrals for 
further care. 

Some clients come in to discuss 
their health problems with people who 
make the time to listen. James is a case 
in point. Although his blood pressure 
is a normal 120/80, he complains of 
heart fluttering, "losing his step," 
dizziness and thirst, and he has a fam- 
ily history of diabetes. Whereas many 
of the clients who visit the van do not 
have a regular health provider, James 
has a primary care doctor at a health 
center just a few blocks away. As he 
describes his symptoms Craig takes 
notes, and after more questions learns 
that James sees a psychiatrist, whom 
he does not like. Craig asks for James's 
primary care doctor's name who will 
be given this information before 
James's next appointment. James came 
in looking disoriented and nervous, 



but as he steps out of the van he looks 
relieved and says thank you several 
times. 

Although James came onto the van 
on his own, van staff also rely on com- 
munity outreach workers like Natacha 
Alexandre to attract clients. Alexandre 
has been working with the van for 
about a year. She serves as a represen- 
tative of the health center on the van 
and also as a representative of the van 
in the neighborhood by doing out- 
reach. 

"It's an excellent program because 
it's preventive and saves lives," says 
Alexandre. "People become familiar 
with the van. They like that it's confi- 
dential and private." Alexandre's skill 
becomes apparent as the van fills to 
standing room capacity. When she 
runs out of flyers Alexandre returns to 
the van and smiles, "I sent you a lot of 
smokers, didn't I?" 

Project coordinator Gittens-Carle, 
who has been on the van the longest, 
has seen the program grow "by leaps 
and bounds" since beginning her work 



A Respected 
Option 

HMS students have always vol- 
unteered their time and skills 
to a variety of causes and ser- 
vices in the community. Now 
an effort is under way to 
acknowledge these students 
with academic credit and 
financial support, just as the 
school does with student par- 
ticipation in research and 
international work. 

As often happens, enei^ by 
both HMS faculty and students 
toward a goal coalesces simul- 
taneously. While Nancy Oriol's 
work with the Family Van 
established her as a public ser- 
vice contact for both faculty 
and students, a group of stu- 



dents were inspired to draft a 
proposal to formalize their 
work in the field. After a highly 
successful presentation to the 
Faculty Council, Dean Tosteson 
asked that a subcommittee be 
formed to review the specifics 
of the proposal, which resulted 
in the subcommittee on public 
service, with Oriol and Gerald 
Fischbach named co-chairs. 

Since then the Faculty Council 
has given its support to an 
honorarium to all students who 
perform significant community 
service, and to the develop- 
ment of a community service 
day, similar in scope to Soma 
Weiss Day. It is now being 
determined how academic 
credit can be given. 



Audrey Bernfield, director of 
the Office for Enrichment 
Programs, is coordinating 
these efforts in conjunction 
with Oriol, Judy Bigby 78 and 
Roxanna Lerner Quinn of the 
Holmes Society. "Our office 
has always tried to work with 
other student groups, but now 
we're saying to students that 
HMS values this and also rec- 
ognizes student debt and the 
need for a stipend," says 
Bernfield. "Labs offer stipends, 
as do international efforts, so 
why not here? We have to 
acknowledge the costs of doing 
community service." 

Oriol points out that although 
90 percent of incoming HMS 
students have done some type 
of community service, this 
number drops to 60 percent 



once students are in medical 
school, often because this 
work is not supported. Oriol, 
who has been honored with an 
award from the Massachusetts 
Medical Society for her work in 
the field, observes that 
"Medical students today are 
more community minded than 
the previous generation. Public 
service needs to be seen for its 
impact on science. It's not just 
about doing good. It's rele- 
vant." 

This acknowledgment is begin- 
ning to come in different ways, 
including financial support. A 
mailing to all faculty chairs 
from Dean Tosteson, Oriol and 
Fischbach has generated 
$36,000, and another mailing 
is in the works. These funds 
will provide a stipend to each 



38 



Harvard Medical Alumni Bulletin 



in August 1992. In the beginning 
Gittens-Carle was the only staff per- 
son on the van, aside from Oriol and 
Dorsey and the driver. The once small 
staff has now grown to team size and 
on the van this morning in addition to 
Gittens-Carle and Baltz, are HSPH stu- 
dent volunteer Proochista Ariana, 
smoking cessation counselor Priscilla 
Elliot, and driver Joaquin Alicea. As 
Gittens-Carle talks it becomes clear 
why she continues to do the work. "I 
like my job. It's the perfect atmos- 
phere to work in, with different people 
and different agencies. You get a sense 
that you're really doing something." 

The numbers certainly confirm that 
the Family Van is doing something 
with over 18,000 client visits since 
opening day. About 60 percent of 
clients are reproductive age, with an 
equal number of men and women vis- 
iting the van. Many of the clients are 
returnees who often bring their 
friends. In 1996 there were over 700 
family planning visits and more than 
800 visits from teenagers. The number 



Most staff live in the 
same neighborhoods 
as their clients. 



of elderly clients is increasing and staff 
note that many of these senior citizens 
are taking care of their grandchildren 
and/or neighborhood children. Often 
after these clients get their blood pres- 
sures checked they ask for diapers and 
formula. "Whatever it takes to make a 
strong family," comments Callahan. 

Indeed van staff want to reach 
everyone in a family, as WIC nutrition- 
ist Baltz notes. "I see everybody, not 
just pregnant parents, but also 
teenagers and grandparents." Baltz 
finds her work satisfying because she 
has had the opportunity to create both 
an affordable and nutritionally sound 
program for van clients. After review- 



ing some statistics she began to sug- 
gest the "Five a Day" nutrition plan 
which promotes fruit and vegetables 
and addresses such health problems as 
heart disease, diabetes and asthma that 
are seen regularly in clients. Yet Baltz 
is sobered by all the work that still 
needs to be done. She makes an 
increasing number of referrals to food 
pantries and says some free meals are 
no longer totally free. "Even if a free 
meal costs a dollar or two, that still 
might be too much for a family." 

The van's success is bittersweet 
since it indicates that the need exists 
and shows no signs of letting up. "If 
our clients no longer needed the van, 
that would be the greatest day ever," 
says Oriol. Oriol worries that as other 
issues vie for public attention funding 
might become difficult. "Having iden- 
tified a need and a solution, it is our 
responsibility to support this success. 
So far we have been fortunate in find- 
ing dedicated funders, but it takes a lot 
of effort." 

The Family Van is unusual in that 



student and will cover the 
costs of Dean Ebert Day, the 
community service day named 
for the late Robert Ebert who 
devoted much of his time to 
the community. This year's 
Dean Ebert Day will be on May 
29, 1997 and students will 
present posters and receive 
certificates and honoraria. 

As with research and interna- 
tional programs, Bernfield says 
one of the goals is to establish 
a centralized clearinghouse for 
HMS students to access infor- 
mation on agencies and pro- 
grams. A formal resource book 
is to be compiled, and already 
there are listings of community 
service openings in Expanding 
Horizons, the newsletter put 
out by the Office of Enrichment 
Programs. 



Some community service work 
has been formalized. One such 
program is the Big Brother/Big 
Sister program at the Judge 
Baker Guidance Center. Fifteen 
HMS students spend one-on- 
one time with students one 
afternoon a week. Students 
also have contact with the 
teachers, psychiatrists and 
social workers of their little 
brothers/sisters, which broad- 
ens their experience. The 
Urban Health Project, a stu- 
dent-run program that was cre- 
ated by HMS students, offers 
many opportunities for student 
participation in the community, 
in addition, there is now a 
community service representa- 
tive on the student council. 



"We're trying to develop pro- 
grams that will continue after 
the student goes to the 
wards," says Bernfield. In the 
past when students worked out 
in the community there was no 
continuity after the students 
left to do their clinical rota- 
tions. Bernfield and her col- 
leagues also want to encourage 
the development of diverse 
programs. For example, a stu- 
dent came to see Bernfield 
about creating a manual on 
Asian languages, since medical 
students are seeing an increas- 
ing Asian population in the 
wards. Already in place is a 
program where students take 
an intensive one-month course 
in Spanish before heading into 
the community to work with 
Hispanic and Latino popula- 
tions. 



Bernfield recently woke up in 
the middle of the night thinking 
about how to make all this 
come together. "First we had 
to raise the money. Now it's 
time to get all the students 
together and hear from faculty 
who are working out in the 
community and want to involve 
students. We're excited and 
the students are eager." 

m 



Spring 1997 



39 



with the exception of \'\^C funding it 
does not reh' on any government assis- 
tance. Over one-third of its $400,000 
budget continues to come from Beth 
Israel Deaconess Medical Center and 
the Beth Israel Deaconess Anesthesia 
Foundation, which suppHes all the 
overhead for the van, office expenses 
and drivers' salaries. Support also 
comes from over 50 private groups, 
corporate sponsors and smaller foun- 
dations. 

In the last few years there have 
been many calls requesting informa- 
tion on establishing the program out- 
side of Boston. The foundation that 
subsidized Dorsey's position and now 
Callahan's — echoing green — has taken 
the lead in supporting the Boston site 
as a national model. The goal, how- 
ever, is not to create exact duplicates 
of the Boston Family Van in every 
city. "The mission is to help other 
cities and towns design their own 
Family Van programs that will meet 
the needs of their specific communi- 
ties," explains Callahan. 

Among Callahan's responsibilities 
is to identify people who can build and 
run their own Family Van programs 
outside of Boston. The initial idea was 
to stay close to home, which is why 
Providence was chosen. Working pri- 
marily from a $1 25,000 grant from the 
H.E.L.P. Coahtion (Health and 
Education Leadership in Providence), 
staff at Women and Infants Hospital 
and Brown University started the 
Family Van in Providence. Callahan 
shuttles back and forth between 
Boston and Providence providing 
technical assistance and moral support 
and will do the same for the next city. 

"We're in the community every 
day, as well as in the institutional 
arena. With several Family Vans, each 
can learn from the other, do larger 
projects and also attract larger fun- 
ders," says Callahan. Aside from serv- 
ing new communities and establishing 
a network, Callahan believes the 
national initiative will eventually 
impact health care policy. In this vein, 
the Children's Health Fund, estab- 



"Students cofne away 
with respect for the 
individual and how 
that person V reaction 
to health care jits 
into their world. " 

— Nancy Oriol 



lished by musician Paul Simon and 
pediatrician Irwin Redlener in New 
York, serves as a model. 

Since van staff hear first-hand what 
issues prevent clients from accessing 
services, they are in a unique position 
to facihtate how local health centers 
can best provide for community resi- 
dents. For example, van staff noted 
that a group of elderly clients returned 
week after week for glucose monitor- 
ing at one particular site. The local 
health center had not been able to 
reach this elderly population very well, 
and with the help of the van, is now 
developing a program to address their 
needs. 

Client needs are never far from the 
minds of van staff and volunteers. 
Clients for whom English is a second 
language are helped by staff and/or 
volunteers who are bilingual. But this 
emphasis on client care is not without 
stress. Gittens-Carle remembers that 
in the early days, without a formal sup- 
port system in place, it was difficult to 
manage some of the feelings that were 
evoked after talking with clients. 
"People come in and unburden them- 
selves and the staff is left with what the 
clients have said to us." 

Now Beth Israel Deaconess 
Medical Center provides social work- 
ers to meet with staff when needed, 
and Gittens-Carle and her colleagues, 
among them project coordinator 
Rainelle Walker, debrief themselves 



and use e-mail to get questions 
answered. Gittens-Carle says now the 
only down side to her job is not always 
knowing what becomes of the clients 
after they visit the van. Efforts are 
under way, however, to develop a 
tracking system. 

This system is just one of the many 
projects in the works, according to 
Boston director Craig. Craig succeeds 
Ramona Hamblin, who had taken the 
reins from Dorsey. Expanding services 
to Chelsea, Hyde Park and Jamaica 
Plain is a possibihty due to the number 
of requests from these neighborhoods. 
The van is seen as part of a continuum, 
says Craig, "an entry point for people 
into Boston's health and social service 
resources. We're working to improve 
coordination of outreach workers and 
other community groups, and plan- 
ning to establish a community advisory 
board." Attention will also be directed 
to augmenting the nutrition program, 
including targeting specific cultural 
groups who may be at risk for diabetes 
and hypertension. And although still in 
the prehminary stages, Craig has been 
collaborating with the March of Dimes 
to coordinate a preconception and pre- 
natal education program. Add a poten- 
tial computerized database to serve as 
a central clearinghouse for social ser- 
vices, and that still does not cover all 
the goals Craig outlines. 

In addition, collaborations with the 
medical community will continue, 
including those with HMS and Boston 
University students and physicians. 
Physician involvement from the 
Harvard community has been signifi- 
cant, with doctors volunteering to do 
staff tasks, and some issue-related ser- 
vices (eye exams, diabetes counseling). 
Craig says these collaborations happen 
both formally and informally. 
"Doctors have been incredibly respon- 
sive. I put out an e-mail and always get 
a response." 

Some pediatric residents from 
Children's Hospital gave a workshop 
on child development, while others 
provided physicals and health educa- 
tion for youth in association with a 



40 



Harvard Medical Alumni Bulletin 



special event at the Suffolk County 
Probate Court. Other collaborations, 
such as Beth Israel Deaconess resi- 
dents giving pre-camp physicals to "at 
risk" youth, occur the way much busi- 
ness is transacted in the busy world of 
Longwood. "I saw the pre-camp physi- 
cals as a means to address the lack of 
safe sex practices that occurs in this 
client group," remembers Oriol. "I 
bumped into the chief of medicine in 
the hall and asked him about having 
his residents do camp physicals, while 
the Family Van staff did family plan- 
ning and safe sex counseling. It was a 
great success." 

"Harvard provides a lot of human 
power," says Callahan, noting there 
have been many students throughout 
the Harvard system who have offered 
their time and skills to the van. 
Trevena Moore, MPH and current 
Harvard Medical student doing a fifth 
year, spent this past year putting her 
public health knowledge into practice, 
or as she describes it, "Taking the 
classroom to the streets." Moore 
wanted to apply the principles of pub- 
lic health research to an emerging 
community-based program. In addi- 
tion, she wanted to hone her medical 
knowledge by helping establish med- 
ical protocols for van workers. "I have 
seen first-hand how people's issues go 
way beyond what we as physicians can 
offer by means of technology and 
health education. We also need exten- 
sive knowledge of the other types of 
services that exist in our clients' com- 
munities." 

Marian Aiken '95 is another HMS 
student who wanted to take a fifth year 
and "do something different." She had 
always been interested in public 
health, and after talking with Oriol 
and spending a day on the van, she 
chose to devote two days a week to 
van-related work for a year. 

Dubbed a "research fellow," Aiken 
was given free rein to work on a vari- 
ety of projects, including collecting 
data on the van's catchment areas, 
developing educational materials and 
creating a database. "I wasn't sure 



what area I wanted to go into after 
medical school and my work with the 
van helped me decide on primary 
care," says Aiken. She describes her 
time on the van as a "family kind of 
experience," which was difficult to 
leave behind. Yet it has had a long- 
term influence on her career: "I want 
to do projects as a doctor that will 
impact the community." 

The value of this work for medical 
students is multi-layered, says Oriol. 
"Students come away with respect for 
the individual and how that person's 
reaction to health care fits into their 
world." Students also gain a better 
understanding of the context of peo- 
ple's lives. "The working poor don't 
have insurance. Doctors only see this 
group at an urgent point and wonder 
why. These clients have a great deal of 
pride. They don't have money or time 
to fill prescriptions. It becomes a real 
learning experience." Indeed, it is 
hoped that these learning experiences 
become formalized so academic credit 
and financial stipends can be received, 
making it as much of a respected 
extracurricular option as research and 
international work. 

As Marian Aiken found, spending 
time on the van can also offer medical 
students a reminder of how fulfilhng it 
can be to give back to the community. 
"You can't do it all," says Boston 
director Craig, who has worked in the 
human service field for close to 30 
years. "But if you help one person 
every day, you've made a difference. 
We see people on the van whose lives 
we've changed." ^ 

Jajiet Walzer is associate editor of the 
Harvard Medical Alumni Bulletin. 



Spring 1997 



41 




Harvey J. Makadon 



"IVho would have guessed that in the next i6 
years this illness would change not only how 
medicine is practiced and drugs are researched^ 
but also would provoke great social change, " 



42 



Harvard Medical Alumni Bulletin 



Legacy of AIDS 



by Harvey J. Makadon 



It was 1 98 1. I PiAD JUST STARTED 
working in a faculty primary care prac- 
tice at what was then called Beth Israel 
Hospital when we began receiving dis- 
turbing reports of strange illnesses 
occurring mostly in gay men. At first it 
was gastrointestinal infections and too 
much hepatitis. Then there were cases 
of Pneumocystis pneumonia (PCP) and 
Kaposi's sarcoma (ks). One night at a 
faculty meeting a colleague described a 
patient as having gay-related immune 
deficiency syndrome, soon to be called 
AIDS. Who would have guessed that in 
the next 1 6 years this illness would 
change not only how medicine is prac- 
ticed and drugs are researched, but 
also would provoke great social 
change. 

Soon the syndromes associated 
with AIDS were also reported in IV 
drug-users, hemophiliacs and eventu- 
ally in others. Fear was widespread; 
many doctors refused to care for those 
with AIDS. Two of my primary care 
colleagues, Booker Bush and Kay 
Petersen, however, were the first to 
truly confi-ont the disease in our prac- 
tice and initiate what was to become a 
national model of primary care-based 
services for people with AIDS. At first I 
was not as eager. It was less fear of 
contagion than fear of the unknown, 
and also fear of being identified as 
what I was and am: a gay physician 
working in a world where at that time 
I could not imagine acceptance. 

Yet a great deal was to change in 
the next decade. Much of this grew 
paradoxically from the epidemic or 
"the plague" that was affecting this 
community. In When AIDS Ends: Notes 
on the Twilight of an Epidemic, Andrew 
Sullivan writes: "AIDS and its onslaught 



imposed a form of social integration 
that may never have taken place other- 
wise. Forced to choose between com- 
plete abandonment of the gay 
subculture and an awkward first 
encounter, America, for the most part, 
chose the latter. A small step, perhaps, 
but an enormous catalyst in the rene- 
gotiation of the gay-straight social 
contract." 

The gay community was not 
merely the passive recipient of this 
first step toward understanding; the 
community itself underwent enormous 
change. Individuals took responsibility 
for friends who became family, and 
advocated for services, using a model 
of self-empowerment adapted in part 
from the women's health movement of 
an earlier decade. It became clear that 
public health and politics were closely 
intertwined. For many of us it forced 
recognition that we needed to stand 
openly and proudly alongside friends 
who were ill, if one were to live an 
honest life and feel any sense of self 
worth. So the world adjusted. At times 
it was not easy, but in the long run, 
AIDS saved many a spirit, possibly 
mine, as it continued to kill the hopes, 
dreams and bodies of far too many 
others. 

My first patient with AIDS was a 24- 
year-old man from Puerto Rico. When 
I first saw him his disease was 
advanced. He remained hopeful 
despite the fact that he had already 
experienced several bouts of PCP and 
was in the hospital being treated for 
cryptococcal meningitis. His parents, a 
thousand miles away, did not under- 
stand. He had two caring sisters and a 
loving partner who looked after him to 
the end. Fortunately, all agreed on 



how his care should be handled when 
he could no longer make decisions for 
himself After he died, he did return 
home. 

AIDS has forced physicians, nurses 
and other clinicians, as well as hospital 
administrators, to confront social, 
political and economic issues that had 
been side-stepped or ignored in the 
past. How they were dealt with varied 
greatly. A resident I worked with had a 
patient with HIV who had an orthope- 
dic problem that required a procedure. 
The consulting orthopedic resident 
said the procedure was elective and he 
would not perform it. Could this be 
permitted? 

Around the nation, answers varied. 
I was pleased that our hospital leader- 
ship made it clear that AIDS was no dif- 
ferent from other illnesses and that all 
patients deserved one standard of care. 
Many other questions were raised and, 
particularly in the early years, there 
were no easy answers. While it took 
time, AIDS has clearly led us to take 
universal precautions seriously, even 
though earlier warnings about hepati- 
tis B exposure had not been heeded by 
many. That is not to say that students 
still do not complain about a resident 
who chides them for taking the extra 
time that safety demands, but progress 
does not make perfect! 

Many situations arose that had 
never been thought through before. In 
retrospect, we did not always get 
things right on the first try. PoHcies 
about admissions to ICUs are an exam- 
ple: many hospitals had clear guide- 
lines that patients with PCP could not 
be admitted, even once, to an ICU. 
Other hospitals ruled that this could 
not be done for second cases, as no 



Spring 1997 



43 



one was known to recover. On what 
basis and with what data were these 
policies set? Was the prognosis of peo- 
ple with PCP different from those 
receiving aggressive treatments for 
incurable cancers who were treated 
routinely in iCUs? Would such rules 
have been made had those at risk for 
AIDS not come from marginalized 
groups (gay men, W drug users, hemo- 
philiacs, with a disproportionate num- 
ber from poor urban communities) 
whose routes to care had not yet been 
embraced by the medical profession? 
V\Tiile we might argue how to use ICU 
resources now based on resource limi- 
tations, would we make decisions that 
were not equitable? 

It seems fortunate that within the 
first few years of the epidemic, those 
with AIDS (first the gay community and 
then many other groups and individu- 
als) grew together and made the med- 
ical community think through its 
decisions, deliberately and often pub- 
licly in ways it had not previously been 
called upon to do. There were many 
areas where this was and continues to 
be true: design of clinical trials to 
include not just white men but women, 
drug users, children, African- 
Americans and Latinos; legal designa- 
tion of lovers and friends as health care 
proxies when traditionally recognized 
family members were not the trusted 
parties; availability of new medications 
for individuals who did not qualify 
under the definitions of clinical trials, 
but who had no other alternative to 
save their lives; the right to work and 
live a life without the daily threat of 
discrimination based on having AIDS. 

The focus for clinicians during the 
first years of the epidemic was on 
treating those who were ill, while for 
researchers in the lab, it was trying to 
understand the nature of the problem 
and its transmission. When it was 
finally determined in 1984 that HIV 
(HTLV-3 as it was then known) was the 
cause of AIDS, it was announced with 
great fanfare. Margaret Heckler, then 
secretary of the Department of Health 
and Human Services, promised that 



Even after the test 
to detect HIV was 
first created in 1985, 
there was little to 
be done medically. 



vaccine trials would be under way 
within two years. But the dawn of the 
era of AIDS treatment came slowly. An 
initial report on the efficacy of 
trimethoprim/sulfamethoxazole 
(tmp/SMX), a mainstay in treating PCP, 
was initially largely ignored. Instead, 
attention was focused on the use of 
aerosolized pentamidine — an expen- 
sive, much marketed treatment which 
has now been demonstrated to be infe- 
rior to and far more expensive than 
TMP/SMX. 

Even after the test to detect Hiv 
was first created in 1985, there was lit- 
tle to be done medically before oppor- 
tunistic infections developed. It was 
not until 1987 that trial results showed 
that people with AIDS or those with 
considerable HIV-related sjrmptoms 
(then called AlDS-related complex or 
arc) could benefit from an old drug — 
azidothymidine or AZT (now called 
zidovudine or ZDV). A study of effec- 
tive treatment in those who were 
asymptomatic had yet to show 
promise. Finally, an NIH study called 
ACTG 019 (AIDS CHnical Trial Group 
019) was discontinued in less than two 
years because data showed that people 
on AZT were less likely to develop AIDS 
or HIV-related symptoms. The study 
also showed that a lower dose was as 
effective, with less toxicity, though 
there was no evidence of increased 
longevity. 

For a time things changed. Had 
hope finally eclipsed reality? However 
fi-agile the findings might seem in ret- 
rospect, we began to develop clinical 



guidelines and ways to look at quality 
of practice. For the first time a consen- 
sus developed on how to treat patients 
with HIV. Some would say it was too 
pat and neat, but the first NiH guide- 
lines for treating those with HIV were 
written in a manner to which the pri- 
mary care provider could relate. The 
guidelines were a step-by-step 
approach analagous to how hyperten- 
sion, not an unknown plague, was 
being treated. Although many patients 
were still skeptical, did not get tested, 
and felt AZT was poison, many did get 
tested and began participating either 
in new cfinical trials or "standard" 
treatment — a recommendation to start 
AZT if T cells were under 500, and 
consideration for PCP prophylaxis if 
under 200. 

Over the ensuing two to three 
years, less robust results were reported 
for AZT and we re-entered a time of 
uncertainty and ambiguity. Many par- 
ticipants in the Berlin AIDS Conference 
in 1993 came back hopeless and angry. 
Strategies had failed; there was not 
enough money; the epidemic was 
spreading with little evidence that pre- 
vention was working; the promised 
vaccine was nowhere in sight. 

Practicing medicine was difficult. 
Patients who had already been on AZT 
and other available treatments hoped 
for a new treatment for HTV but had to 
do the best they could with prophy- 
laxis against opportunistic infections. 
Sessions with patients who were hav- 
ing new symptoms were spent watch- 
ing T cell counts fall — quiet, often 
tense, again surrounded by uncer- 
tainty, wondering about everjnJiing 
except the ultimate outcome. Was it 
different from cancer treatment? 
Probably not. Yet everyone was so 
young, so disfigured, with so little time 
left to achieve what could be. 

I remember organizing an AIDS 
training session for physicians in 
Oregon and being in a small discussion 
group when one of the doctors said he 
felt he could not keep one image out 
of his mind: Whenever he sat with a 
new patient with HIV, he felt like there 



44 



HUrvarjd Medical Alumni Bulletin 



was a video picture in his brain, watch- 
ing a man run from hfe to wasting 
towards death. The only time I had 
this experience was during this time, 
when there was so httle to do and so 
many in need. 

I continued my practice, but also 
found myself turning my academic and 
educational interests to Hiv preven- 
tion — a constructive way to channel 
both frustration and energy. 
Prevention had never truly been a sig- 
nificant part of medical education. It 
was only when I was a resident in the 
primary care program at Beth Israel 
that clinicians like Bill Taylor and Bob 
Lawrence '64 made it clear that pre- 
vention was important to learn and 
practice. 

During meetings to evalute how to 
involve physicians in HIV prevention, I 
was surprised that both public health 
officials and behavioral scientists 
reacted less than enthusiastically to the 
notion that clinicians should play a 
role in HIV prevention efforts. The 
idea was greeted with concerns about 
whether they should spend the time, 
whether it was worth their time, and to 
be honest, whether it was an appropri- 
ate role for physicians. 

I asked about the impact of a physi- 
cian's silence. What message does it 
give patients if their provider does not 
bring up the subject of HIV preven- 
tion? Is it analogous to not talking 
with someone at high risk for coronary 
disease about whether they smoke and 
helping them to stop? Physicians, in 
particular, can respond to questions in 
areas where data are ambigious in ways 
that public health or social marketing 
slogans often cannot. 

As Eric Rofes writes in his book 
Reviving the Tribe, "Marketing strate- 
gies often encourage men to consider 
sex acts as narrowly defined and cir- 
cumscribed, requiring only simple dis- 
creet adjustments to be made safe, like 
an automobile with bad brakes. Yet 
erotic activity is complex and varie- 
gated, difficult to categorize and con- 
trol, and filled with competing 
meanings." The physician visit offers 



Hope has gained 
ground; people are 
living longer. 



the opportunity to engage in a more 
complex dialogue that can include, as 
Jonathan Silin and I describe in a 
paper, a "reciprocal search for mutual 
understanding in which culture and 
values are considered." 

Now in 1997 the biggest question 
facing us is whether we have, in fact, to 
quote Andrew Sullivan again, "come to 
the twilight of the epidemic" and if so, 
whether and how this will ever be true 
globally. The introduction of protease 
inhibitors — expensive proteins that act 
at the end of the viral replication cycle, 
preventing the assembly and release of 
new HIV virions from CD4 cells — as 
routine treatment has revolutionized 
HIV care, but they are hard to produce. 
They have been shown, in combina- 
tion with nucleoside analogues like 
AZT or d4T with 3TC, to have remark- 
able effects on immune function, and a 
two- to three-fold greater ability to 
decrease the amount of virus in blood 
than any previous treatment. 

How true this is for all, how long- 
lasting the effect will be, and whether 
these drugs will be affbrdably pro- 
duced so that they can be used outside 
the developed world and even by those 
within it, are major questions. It is 
clear they work and allow individuals 
who were wasted to regain both their 
spirit and their bodies. Hospices, like 
the heralded hospice on Mission Hill 
near the Harvard medical area, are 
closing for lack of patients. And the 
San Frajicisco Bay Area Reporter 
recently ran the headline, "Is it Time 
for the San Francisco AIDS Foundation 
to Downsize?" 

These are indications that, at the 
very least, the epidemic is changing. 
Hope has gained ground; people are 



living longer. Many on disability pen- 
sions who had cashed in their life 
insurance are wondering what they 
will do next. But despite headlines 
heralding the possible eradication of 
the virus, a "cure" is still not attain- 
able. It seems that for many, at best, 
the virus will be contained. The ques- 
tion is, for how long? Many have 
already experienced the failure of pro- 
tease drugs and are watching their viral 
loads climb. This is particularly true 
for those who have been on many 
medications in the past and have 
already developed varying levels of 
resistance. Will we again see an 
increase in the number of those suc- 
cumbing to opportunistic infections, 
or will there be new protease 
inhibitors that are more powerful, with 
different resistance patterns to be used, 
possibly in combination with other 
therapeutic strategies that will boost 
the power of dysfunctional immune 
systems? 

We face great questions at the end 
of the twentieth century. Will we 
make progress with new therapies fast 
enough to truly save those who are 
infected, and make them available for 
all who need them? We still must do 
what we can to keep new individuals 
from getting infected. But how will 
this be done when we cannot legally 
promote the most effective means to 
prevent the spread of HIV openly and 
honestly in our subways, on our televi- 
sions and in our schools. Finally, given 
the growth of the global epidemic, will 
we ever cure AIDS without eradicating 
AIDS globally? We have seen that 
developing nations have the will to 
engage in successful prevention efforts, 
but can it be done to the extent neces- 
sary, with the available resources? 

AIDS has changed many of our lives. 
In fact, much about the way we do 
many things — from basic research and 
making new study drugs available to 
new drug approval and the way we 
work with our patients — have 
changed, in part, as a result of AIDS. 
People with AIDS have shown that they 
can and will work with the medical 



Spring 1997 



45 



comniunit}' to make the entire medical 
industrial complex more responsive to 
the needs of those who have or are at 
risk for HR'. Early protests against 
governmental policies on MDS research 
ultimately changed to a more responsi- 
ble form of involvement by the com- 
munity. 

Reviewing the book, hnpure Science: 
AIDS, Activism and the Politics of 
Knowledge in the New York Times, 
Jeffrey Goldberg writes: "It is not sim- 
ply that AIDS activists began to under- 
stand the implications of double-blind, 
placebo-controlled tests that is so 
important; what matters most is that in 
reaction to the educated criticism of 
AIDS activists, government officials 
actually changed the way the science 
was done." In many ways, what is 
remarkable, he continues "is the revo- 
lution, sparked by AIDS, in the way dis- 
eases are studied and the practice of 
medicine is conducted... Lessons can 
be drawn — and are being drawn — by 
those who in the past were simply pas- 
sive patients, relying almost entirely 
on medical experts to battle their ill- 
nesses as they saw fit: as the AIDS 
movement is showing, people with dis- 
eases (and those at risk for getting 
them) can play a profound part in sav- 
ing themselves." 

One must wonder if things would 
have been different had AIDS been a 
disease that affected mainstream 
America. Yet there has been great 
change. Now, if we can only incorpo- 
rate into our practices what we have 
learned from AIDS, we will be in a bet- 
ter position to understand the needs of 
our patients and work together to 
champion changes in health care that 
will improve the health of the public, 
as well as the health of our profession 
and our own satisfaction in the century 
ahead. ^ 



Will we make 
progress with new 
therapies fast enough 
to truly save those 
who are infected^ and 
make them available 
for all who need 
them? 



Harvey J. Makadon is associate professor 
ofjnedicine at HMS and vice president and 
medical director ofAmbulatoij Care and 
Community Health at Beth Israel 
Deaconess Medical Center. 



46 



Harvard Medical Alumni Bulletin 



Medicine in 
Coal Country 



by Daniel Doyle 




A coal company in 
Appalachia. 



Spring 1997 



47 



Twenty \'e.\rs ago last spring, a 
group of West Virginia coalminers 
and their neighbors founded the New 
River Health Association and set out 
to build the New River Family Health 
Center. It was built right on top of old 
A^ingrove Mine slate dump, along 
WTiite Oak Creek. Lucky for me, I was 
there to help it happen, and to keep it 
happening ever since. 

Access to health care — for them- 
selves, their extended families and 
their community — that is what it was 
all about. Assuring and improving 
access to health care for one under- 
served Appalachian community is the 
soul of the New River Health 
Association (nrha), Fayette County, 
West Virginia. 

In the spring of 1970, Joe Gardella, 
HMS dean of students, conducted per- 
sonal interviews with every member of 
the class of 1972. We knew his agenda: 
to query and counsel us about appro- 
priate career plans. My friends and I 
fancied ourselves the nonconformists 
of the class. We approached this inter- 
view with both trepidation and trucu- 
lence. We knew that Dr. Gardella 
wanted to know about residency plans 
and the development of a research 
interest. 

The Vietnam War was raging. 
Kent State and its aftermath were only 
a few months away. Some of us were 
more preoccupied with the direction 
of American society than the direction 
of our careers. I was concerned and 
confused about both. What could I say 
to Dr. Gardella? 

The day arrived. I walked into the 
office, closed the door, and sat down 
on the couch facing his desk. Each of 
us had the other's number. 

"So Mr. Doyle, what sort of career 
plans do you have in mind after med- 
ical school?" 

Compelled by irreverence and per- 
versity, I blurted out, "I was thinking 
I'd be a family doctor in Appalachia." 

"Well, if you are going to go there 
and do some meaningful research, it 
might be OK. But if you're just going 
to be putting bandaids on people, it 



The first few years 
were exhilarating 
and exhausting. 



seems like an awful waste." Shortly 
thereafter the interview ended. 

Eight years later, my wife, Linda 
Stein, and I enjoyed our first 
Appalachian spring. The redbud and 
dogwood lit up the steep West 
Virginia hillsides, followed a few 
weeks later by every shade of green. 
We had come to Fayette County to 
work with the NRHA, whose founders 
wanted to form a community health 
center so it would be easier for people 
to get in to see a doctor and not have 
to travel so far. They wanted better 
communication. They wanted things 
explained. They wanted preventive 
care, especially for women and chil- 
dren. 

My wife was a health educator with 
a fine arts degree from Carnegie- 
Mellon, an MEd from University of 
Massachusetts, and six years experi- 
ence in mental retardation programs 
with the Massachusetts Department of 
Mental Health. Since my interview 
with Dr. Gardella, I had taken a two- 
year leave of absence from HMS to do 
community health work in Mission 
Hill and to put on bandaids as an 
orderly at Boston City ER. I graduated 
in 1974, did a rotating internship at 
Cambridge City, and completed a 
family practice residency at UMass in 
July 1977. We arrived in West 
Virginia that fall. 

We had discovered West Virginia 
thanks to Craig Robinson, the son of a 
SLiNY/Buffalo psychiatrist, who had 
come to West Virginia as a VISTA vol- 
unteer in 1967. He was organizing 
community clinics for the United 
Mineworkers of America when he 
recruited us in 1976. 1 then recruited 
him to be clinic administrator. We 



persuaded the penniless NRHA board to 
appoint us as their initial management 
team, and Craig led us to the Rural 
Practice Project of the Robert Wood 
Johnson Foundation. The Rural 
Practice Project was trying to establish 
ten "model rural practices" around the 
U.S. based on a model of community 
responsive practice and physician- 
administrator leadership teams part- 
nered with nonprofit community 
groups. 

After successfully completing their 
initiation rites, including a detailed 
clinical and business plan for our 
fledgling practice, they awarded the 
NRHA $412,000 to support clinic oper- 
ations over the first three years. We 
opened our doors on June 8, 1978. 

The first few years were exhilarat- 
ing and exhausting. Local physicians 
were skeptical about a doctor who 
chose salaried practice instead of pri- 
vate practice. They were resentful of 
an organization that received federal 
and state funds to compete with them, 
even if it was nonprofit. Although 
most of the insured families of our 
community (including NRHA board 
members) preferred the Beckley 
Hospitals 20 miles away, I took care of 
patients in the nearby 80-bed Oak Hill 
Hospital. Along with two excellent 
PAS, we did general family practice, 
including prenatal care. 

Our practice grew, gathering an 
interesting mix of indigent, Medicaid, 
Medicare, HMO, and insured patients, 
pretty much in that order. We were 
never a "free clinic," but we billed 
whatever insurance people had. If they 
had nothing, we saw them on a sliding 
scale that slid right down to zero. By 
the end of 1 984 we had four doctors, 
two PAs, 30 employees, and a brand 
new facility. We were providing 
20,000 visits to 6,700 users per year. 

In the spring of 1984, Linda and I 
had our first son, Ben, and moved into 
a house we had just built. I took advan- 
tage of Ben's birth to resign as medical 
director of NRHA and pass the torch to 
a younger and very qualified colleague, 
Mike Herr, DO. By this time, NRHA 



48 



Harvard Medical Alumni Bulletin 



was providing more and more services 
that neither began with me nor rehed 
on me. That is one of the greatest sat- 
isfactions of a community organizer: to 
see your organization reach the point 
where it will carry on without you. 

The period of 1984 to 1990 was a 
time of steady growth for NRHA. As 
our practice grew, so did the challenge 
and frustration of providing good pri- 
mary care to a population that was 
poor, sick and uninsured. The CDC 
Behavioral Risk Factor Survey annu- 
ally finds West Virginia with high 
rates of smoking, obesity and inactiv- 
ity. These habits translate to high rates 
of diabetes, premature cardiac disease 
and chronic obstructive pulmonary 
disease (COPD) in our community. The 
danger of work in mining and timber, 
combined with the lack of other good 
jobs, fosters dependence on compensa- 
tion. Social Security and welfare for 
economic survival. 

Because many of our patients had 
no insurance at all, we learned to take 
the patchy benefits of state and federal 
programs, such as family planning, 
cancer control, perinatal services, 
pediatric health services, immuniza- 
tions, black lung and workers compen- 
sation, and integrate them into our 
regular primary care system^ Hospital 
care was usually not a problem as long 
as we admitted the uninsured patients 
ourselves. Often we felt more like 
gatecrashers than gatekeepers as we 
got on the phone and begged for spe- 
cialists to take a 14-year-old boy with a 
complicated fracture or a young 
mother with an ectopic pregnancy. 
Advocating for our patients became an 
integral part of caring for them. 

We joined with the Vanderbilt 
Center for Health Services to estabhsh 
the Maternal Infant Health Outreach 
Worker (mihow) project. Linda 
played a big role here. MIHOW identi- 
fied and trained local women, "natural 
helpers," to provide in-home advocacy 
and support to high-risk women dur- 
ing pregnancy and early infancy. And 
when local women without private 
insurance found themselves virtually 



As a society we must 
decide that access is 
first and that no one 
can he left out. 



locked out of prenatal care because of 
a political impasse between West 
Virginia Medicaid and the private 
obstetrics community, we envisioned a 
local birthing center staffed by certi- 
fied nurse midwives. 

All the while, our direct primary 
care services, home visits, in-patient 
hospital services, and nursing home 
work were growing. We also found we 
had a steady stream of health profes- 
sions students — MD,DO, PA, NP — doing 
clinical rotations with us from both in- 
state and out-of-state schools. Clinical 
teaching, including teaching primary 
care research skills, was becoming an 
ever larger part of our institutional 
mission. 

In 1990 the U.S. Public Health 
Service and the American Medical 
Student Association sponsored a con- 
ference in Washington, D.C. on com- 
munity responsive practice. I was 
invited to speak on the role of the fam- 
ily physician, which made me reflect 
on the evolution of my values and phi- 
losophy with the NRHA over the previ- 
ous 12 years of practice. I called the 
talk "Ten Commandments of 
Community Responsive Practice" (see 
page 50). 

In preparing this talk I discovered a 
fundamental fact about general prac- 
tice. The good general practitioner 
really specializes in "place." With long 
service, she or he acquires an intimate 
and practical familiarity with individu- 
als and families, with house by house 
geography, and with the stores, tav- 
erns, schools, churches, and work- 
places of a particular community, in 
addition to the endemic diseases, hos- 



pitals, specialists, folk healers, drug- 
stores and home health agencies of 
that community. This is only a start. 
There are also the customs, religions, 
foods, songs, dialects, dress and so 
much more. And in the work of diag- 
nosis and healing, the good general 
practitioner draws upon such knowl- 
edge just as much as on the universal 
body of medical knowledge. It is a 
wonderful feeling to be so at home and 
so needed in one little patch of Mother 
Earth. 

The nineties have begun a new era 
for the NRHA, an era of mature service 
and regional influence. Service 
remains first. Staying true to that pri- 
ority and demonstrating both the con- 
tent and processes of real-world 
community responsive primary care 
are among the most important things 
we teach. We believe those are lessons 
for all students, not just those headed 
for general medicine or primary care 
careers. 

Like most of the families in our 
community, the NRHA still struggles to 
survive financially. Limited access to 
financial capital is often a brake on our 
growth even when its direction is 
clear. But with 20 years of service and 
experience, NRHA has created a valu- 
able store of a different kind of capital: 
social capital. This social capital con- 
sists of rootedness in our community, a 
firm and seasoned grasp of community 
medicine principles, a reputation for 
excellence in service and education, 
organizing skills and technical exper- 
tise that we are willing to share, and a 
trusted nonprofit entity able to serve 
as fiscal agent for new local initiatives. 
This social capital has been welcomed 
and needed throughout our state and 
region in this era of medical education 
reform, network building, and corpo- 
rate buyouts. A few examples serve to 
illustrate. 

The birthing center is now a real- 
ity. Since 1992 our three certified 
nurse midwives have delivered 135 
babies and provided prenatal care to 
1,590 women. A new 6,000 square foot 
birthing center is under construction 



Spring 1997 



49 



with a $484,000 FMHA loan. 

School-based health clinics have 
become an exciting new service area 
for us during diis era. Medicaid statis- 
tics revealed school-aged children as a 
major underserved population in our 
county and throughout our state. 
NRHA obtained funding from the state 
and foundations to establish school 
health clinics in three elementary 
schools, three middle schools and one 
high school serving 912 students or 62 
percent of the student population at 
those schools. The local school board, 
superintendent, school principals, 
PTOs and West Virginia University 
Department of Psychiatry have all 
been important partners in this effort. 

That peculiar phenomenon of 
managed care without universal access 
to care has been slow in coming to 
West Virginia but it is finally arriving. 
Through our membership in the West 
Virginia Primary Care Association 
(\^^VPCA), and its managed care com- 
mittee, our CEO Craig Robinson is 
leading an effort to prepare the non- 
profit community clinics of the state 
for the transition to managed care, 
especially the capitated Medicaid 
species. This has included training 
workshops for administrators and clin- 
ical directors, an e-mail discussion 
group for clinical directors, and an 
effort to establish a WVPCA-owned 
HMO with the community health cen- 
ters as equity partners. 

In 1 99 1, through a competitive 
process, NRHA was selected as one of 
ten rural academic centers to make up 
the West Virginia Rural Health 
Education Partnership which grew out 
of a six million Kellogg grant matched 
with an additional six million in state 
funds. As this partnership succeeds in 
its statewide mission of community 
health promotion and community- 
based health professions education, the 
social capital of the whole state grows. 

In some ways Dr. Gardella was 
right. Research and teaching can be 
priceless parts of a physician's career, 
even one destined for a career of direct 
patient care in a distant holler of rural 
Appalachia. 



And yes, it is not enough to put on 
bandaids. For all the good work that 
NRHA does, our reach and impact are 
limited. The 600 community health 
centers of the U.S. are a vital part of 
the fraying safety net that helps to pro- 
tect the poor. But we are only a 
bandaid on the disgraceful wound of 
30 to 40 million uninsured Americans 
in a nation with the largest per capita 
health expenditure in the world. 

As a society we must decide that 
access is first and that no one can be 
left out. As a profession we should 
insist on that social decision. And as 
physicians we should not rest until the 
gaping wound of exclusion is healed. 

Daniel Doyle '72, one of the founders of 
the New River Family Health Center in 
Scarbro, West Virginia, has worked as a 
family practice physician for ig years. This 
past fall he was named rural physician of 
the year by the West Virginia Medical 
Association. 



The Ten Commandments of Community 
Responsive Practice 
by Daniel Doyle 

1. Service is first. Thou shalt not put false 
priorities before this. Preach access and 
practice it. 

2. Thou shalt be a good clinical practi- 
tioner. Listen to people; respect people; be 
thorough; practice cost effectively; support 
QA; get CIVIE. 

3. Thou shalt know where your patients 
live and who they live with. 

4. Thou shalt define community geograph- 
ically. No one may be left out. 

5. Honor thy community and its right to 
participate in planning and decision mak- 
ing. 

6. Thou art not an expert outside thy field. 
Medical school made you an expert on 
medicine but not on architecture, finance, 
politics or civic affairs. In these matters 
community members are your peers and 
your teachers. 

7. Thou shalt take the initiative to get 
involved in practice planning and decision 
making. Don't stand on the sidelines and 
pout about being left out. 

8. Thou shalt not put work before family. 

9. Thou shalt be a scientist working on the 
cutting edge of health promotion methods 
and health services technologies. 

10. Thou shalt not panic when reading 
medical economics. Money is a poor mea- 
sure of personal success. 



50 



Harvard Medical Alumni Bulletin 






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